Saunders NCLEX Questions-Gastrointestinal
A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 3 mg/dL (1.08 mmol/L) 2. 15 mg/dL (5.4 mmol/L) 3.29 mg/dL (10.44 mmol/L) 4.35 mg/dL (12.6 mmol/L)
2. 15 mg/dL (5.4 mmol/L) The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44 mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.08 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.
The nurse is preparing to administer prescribed medications to a client with hepatic encephalopathy. The nurse anticipates that the primary health care provider's prescriptions will include which medication? 1. Bisacodyl 2.Lactulose 3.Magnesium hydroxide 4.Psyllium hydrophilic mucilloid
2.Lactulose Lactulose is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH and aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Bisacodyl is a stimulant laxative. Magnesium hydroxide is a saline laxative. Psyllium hydrophilic mucilloid is a bulk laxative.
A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? 1. Discontinue the enema. 2.Reassure the client, and continue the flow. 3.Raise the enema bag so that the solution can be completed quickly. 4.Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect.
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider? 1. Stoma is beefy red and shiny 2.Purple discoloration of the stoma 3.Skin excoriation around the stoma 4.Semi-formed stool noted in the ostomy pouch
Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2.Positive Cullen's sign 3.Complaints of indigestion 4.Palpable mass in the left upper quadrant 5.Pain in the upper right quadrant after a fatty meal 6.Vague lower right quadrant abdominal discomfort
During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.
A client has an as-needed prescription for ondansetron. For which condition(s) should the nurse administer this medication? 1. Paralytic ileus 2.Incisional pain 3.Urinary retention 4.Nausea and vomiting
Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect reasons for administering this medication.
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? 1. "I need to limit my intake of dietary fiber." 2."I need to drink plenty, at least 8 to 10 cups daily." 3."I need to eat regular meals and chew my food well." 4."I will take the prescribed medications because they will regulate my bowel patterns."
1. "I need to limit my intake of dietary fiber." IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.
Which finding suggests to the nurse that a client with bleeding esophageal varices is experiencing a side or adverse effect of vasopressin therapy? 1. Complaints of chest pain 2.Bounding peripheral pulses 3.Temperature of 102º F (39.8º C) 4.Blood urea nitrogen (BUN) of 20 mg/dL (7.1 mmol/L)
1. Complaints of chest pain Vasopressin therapy causes vasoconstriction, and side and adverse effects include myocardial ischemia, which may be evident by the client's complaints of chest pain. Elevated temperature, bounding peripheral pulses, and a BUN of 20 mg/dL (7.1 mmol/L) are not adverse effects. Vasopressin therapy can cause hypothermia. Because vasopressin has potent vasoconstrictive effects on the peripheral arterioles, weak versus bounding pulses may be found. The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1. Dark red drainage 2.Dark brown drainage 3.Green-tinged drainage 4.Light yellowish-brown drainage
1. Dark red drainage For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1. Rice 2.Whole milk 3.Broiled fish 4.Baked chicken
2.Whole milk Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.
The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? 1. The client reports some pain before meals. 2.The client frequently is awakened at 2 a.m. with heartburn. 3.The client has eliminated any irritating foods from the diet. 4.The client's pain is minimal with histamine H2-receptor antagonists.
3. The client has eliminated any irritating foods from the diet. Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2."Meat does not provide iron and should be avoided." 3."The iron is best absorbed if taken on an empty stomach." 4."On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement."
3."The iron is best absorbed if taken on an empty stomach." Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.
The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? 1. A pale color 2.A purple color 3.A brick-red color 4.A large amount of red drainage
3.A brick-red color Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.
A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion? 1. Protein level of 72 g/L (7.2 g/dL) 2.Ammonia level of 98 mcg/dL (60 mcmol/L) 3.Magnesium level of 1.7 mEq/L (0.85 mmol/L) 4.Total bilirubin level of 1.2 mg/dL (20.5 mcmol/L)
The normal serum ammonia level ranges from 10 to 80 mcg/dL (6 to 47 mcmol/L). High levels of ammonia can result in encephalopathy and coma. The other blood levels are not related to hepatic encephalopathy and are also normal values.
The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma? 1. Massage the area below the stoma. 2.Take in high-fiber foods such as nuts. 3.Limit fluid intake to prevent diarrhea. 4.Cleanse the peristomal skin meticulously.
The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.
The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1. Flat neck veins 2. Abdominal distention 3. Hemoglobin of 14.2 g/dL (142 mmol/L) 4. Platelet count of 600,000 mm3 (600 × 109/L)
With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).
A client admitted to the medical nursing unit has a diagnosis of gastroesophageal reflux disease (GERD). Metoclopramide has been prescribed 4 times a day. When should the nurse schedule administration of the medication? 1. Every 8 hours 2.With meals and at bedtime 3.Right after meals and at bedtime 4.30 minutes before meals and at bedtime
4.30 minutes before meals and at bedtime Metoclopramide is a gastrointestinal stimulant. Administration should be scheduled 30 minutes before meals and at bedtime to allow the medication time to begin working before food intake and digestion. The other options are incorrect.
A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3(300 × 109/L). The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2.Report the abnormally high count. 3.Place the client on bleeding precautions. 4.Place the normal report in the client's medical record.
4.Place the normal report in the client's medical record. A normal platelet count ranges from 150,000 to 400,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.
The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1. Colectomy 2. Appendectomy 3.Ascending colostomy 4.Small bowel resection
4.Small bowel resection The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options.
The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? 1. Sodium 2.Creatinine 3.Hemoglobin 4.Ammonia
A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.
The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? 1. "I can eat whatever I want." 2."I will eat rice cereal for breakfast." 3."I will eat beef barley soup for lunch." 4."I will eat only wheat bread for a snack."
A client with celiac disease should be instructed to avoid gluten-containing products such as wheat, barley, oats, and rye.
The client with peptic ulcer disease is prescribed medication therapy. The nurse explains the medications to the client and explains that sucralfate will help to heal the ulcer by doing what? 1. Reduce gastric acidity. 2.Treat bacterial infection. 3.Enhance mucosal defenses. 4.Eradicate Helicobacter pylori.
Medication therapy is used to treat peptic ulcer disease by 3 mechanisms: eradicating H. pylori(or other bacterial infections), reducing gastric acidity, and enhancing mucosal defenses. Sucralfate works by enhancing mucosal defenses. Antibiotics treat infection and eradicate H. pylori. Antisecretory agents, misoprostol, and antacids work by reducing gastric acidity.
An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply. 1. Past profession 2.Physical fatigue 3.Limited mobility 4.Sensory decreases 5.Inadequate dental care 6.Family history of malnutrition
Other factors besides cognitive status that can increase the risk of malnutrition and dehydration include physical fatigue, limited mobility, sensory decreases, and inadequate dental care. Past profession and family history of malnutrition do not increase one's risk for malnutrition.
A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1. Assist the client in expressing feelings. 2.Restrict visitors until the jaundice subsides. 3.Perform most of the activities of daily living for the client. 4.Provide information to the client only when he or she requests it.
The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.
A client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse should teach the client to include which food in the diet to reduce odor? 1. Eggs 2.Yogurt 3.Broccoli 4.Cucumbers
The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods. There are also optional charcoal filters that can deodorize the colostomy.
A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1. Fat 2.Protein 3.Carbohydrate 4.Water-soluble vitamins
The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2.Instruct the client to limit fluid intake to avoid urinary retention. 3.Encourage a high-fiber diet to promote bowel movements without straining. 4.Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5.Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
1. Administer stool softeners as prescribed. 3.Encourage a high-fiber diet to promote bowel movements without straining. 4.Apply cold packs to the anal-rectal area over the dressing until the packing is removed. Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item(s) are acceptable in the diet? 1. Baked fish 2.Fried chicken 3.Sauces and gravies 4.Fresh whipped cream
1. Baked fish The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. The correct option is baked fish, which is low in fat.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1. Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal marg
1. Inability to pass flatus An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.
The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include in the postoperative discharge plan of care? Select all that apply. 1. Wound care 2.Follow-up care 3.Activity restrictions 4.Dietary instructions 5.Deep-breathing exercises
1. Wound care 2.Follow-up care 3.Activity restrictions 4.Dietary instructions The type of planning and instructions required vary with the individual client and the type of surgery. Specific instructions that this client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the preoperative period.
The nurse is caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which client problem should be the priority? 1. Risk for dehydration caused by bleeding in the gastrointestinal tract 2. Risk for choking and aspiration related to a poor gag reflex post procedure 3. Lack of knowledge of post procedure care related to not having had an EGD before 4. Sore throat related to passage of the endoscope through the pharyngeal region during EGD
2. Risk for choking and aspiration related to a poor gag reflex post procedure EGD is a visual inspection of the esophagus, stomach, and duodenum using a fiber optic endoscope. All the client problems listed as options are potentially appropriate for a client who just had an EGD. After the procedure, the client is recovering from the use of conscious sedation and the administration of a local anesthetic to the throat. Therefore, the client problem in option 2 is most important at this point because of the potential for airway problems.
A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1."I should avoid drinking alcohol." 2."I can go back to work right away." 3."My partner should get the vaccine." 4."A condom should be used for sexual intercourse."
2."I can go back to work right away." To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.
The nurse is caring for a client admitted with severe weight loss due to dieting. Based on the data provided, which condition should the nurse suspect is occurring in this client? 1. Lactic acidosis 2.Glycogenolysis 3.Gluconeogenesis 4.Glucose metabolism
3.Gluconeogenesis Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid resulting from anaerobic metabolism. The body normally burns glucose for energy.
The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease? 1. Blood in the stool 2.Chalky gray stool 3.Loose, watery stool 4.Dry, hard, constipated stool
3.Loose, watery stool Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the primary health care provider (PHCP). The nurse should contact the PHCP to question which prescription if noted in the client's record? 1. Maintain a semi-Fowler's position. 2.Maintain on NPO (nothing by mouth) status. 3.Apply a heating pad to the lower abdomen for comfort. 4.Initiate an intravenous (IV) line with the administration of IV fluids.
Appendicitis should be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi-Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat should never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.
The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2.Checking for normal pH of the gastric aspirate 3.Checking for proper nasogastric tube placement 4.Checking for the presence of bowel sounds in all 4 quadrants
Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriateaction in the care of this client? 1. Obtain a court order for the surgery. 2.Have the charge nurse sign the informed consent immediately. 3.Send the client to surgery without the consent form being signed. 4.Obtain a telephone consent from a family member, following agency policy.
Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a primary health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? 1. Lying recumbent following meals 2.Consuming small, frequent, bland meals 3.Taking H2-receptor antagonist medication 4.Raising the head of the bed on 6-inch (15 cm) blocks
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax following meals and during sleep.
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate? 1. Encourage foods that are high in protein. 2.Monitor for fluid and electrolyte imbalance. 3.Explain that high-fat diets usually are better tolerated. 4.Explain that most daily calories need to be consumed in the evening hours.
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.
The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. 1. Antidiarrheal 2.Antimicrobial 3.Corticosteroid 4.Aminosalicylate 5.Biological therapy 6.Immunosuppressant
Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).
The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1. Chili 2.Bagel 3.Lentil soup 4.Watermelon
The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? 1. "It will cause diaphoresis and diarrhea." 2."I have to monitor for hiccups and diarrhea." 3."It will be associated with constipation and fever." 4."I have to monitor for fatigue and abdominal pain."
1. "It will cause diaphoresis and diarrhea." Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. The remaining options are not signs of dumping syndrome.
The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1. Encourage the client to ambulate. 2.Position the client on the left side. 3.Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4.Discourage the use of the patient-controlled analgesia (PCA) machine.
1. Encourage the client to ambulate. Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications.
The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the primary health care provider? 1.Elevated serum bilirubin level 2.Below normal hemoglobin concentration 3.Elevated blood urea nitrogen (BUN) level 4.Elevated erythrocyte sedimentation rate (ESR)
1.Elevated serum bilirubin level Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.
The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? 1. "I walk 1 to 2 miles every day." 2."I need to decrease fiber in my diet." 3."I have a bowel movement every other day." 4."I drink 6 to 8 glasses of water every day."
2."I need to decrease fiber in my diet." An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.
Dicyclomine hydrochloride has been prescribed for a client with irritable bowel syndrome, and the nurse provides instructions to the client about how to take this medication. Which statement, if made by the client, indicates an understanding of how to take this medication? 1. "I should take the pill with food and at mealtimes." 2."I should take the pill 30 minutes before each meal." 3."I should take the pill after I have finished eating my meal." 4."I should take the pill when I first wake up in the morning and right before I go to bed."
2."I should take the pill 30 minutes before each meal." Dicyclomine hydrochloride is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome that is unresponsive to diet therapy. To be effective in decreasing bowel motility, antispasmodic medication should be administered 30 minutes before meals. The other options are incorrect.
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2.Increase intake of fluids, including juices. 3.Eat a good supper when anorexia is not as severe. 4.Eat less often, preferably only 3 large meals daily.
2.Increase intake of fluids, including juices. Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right
2.Leukocytosis with a shift to the left Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appendicitis.
Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1. Vomiting occurs. 2.The fecal pH is acidic. 3.The client experiences diarrhea. 4.The client is able to tolerate a full diet.
2.The fecal pH is acidic. Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.
A client diagnosed with peptic ulcer disease is prescribed an over-the-counter antacid suspension containing aluminum hydroxide, magnesium hydroxide, and simethicone. What should the nurse include in the client instructions for time of administration of this medication? 1. Just before each meal 2.An hour before breakfast 3. 1 and 3 hours after meals 4.Immediately after each meal
3. 1 and 3 hours after meals Antacids are alkaline compounds that neutralize stomach acid. The objective of peptic ulcer therapy is to promote healing in addition to relieving pain. Consequently, antacids should be taken on a regular schedule, not just in response to discomfort. In the usual dosing schedule, antacids are administered 7 times a day: 1 and 3 hours after each meal and at bedtime. Thus, option 4 is the correct option. Options 1, 2, and 4 are incorrect because they are either not the correct timing or not often enough as recommended.
A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration? 1. Drink 8 ounces of water between taking each medication. 2.Administer the cimetidine and magnesium hydroxide at the same time twice daily. 3.Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. 4.Collaborate with the primary health care provider (PHCP), as the client should not be receiving both medications.
3.Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.
A client with portosystemic encephalopathy is receiving oral lactulose daily. The nurse should check which item to determine that this medication has been effective? 1. Lung sounds 2.Blood pressure 3.Blood ammonia level 4.Serum potassium level
3.Blood ammonia level Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portosystemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, blood pressure, or serum potassium level.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? 1. Call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction.
3.Check the suction device to make sure it is working. After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.
The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? 1.Elevated level of pepsin 2.Decreased level of lactase 3.Elevated level of amylase 4.Decreased level of enterokinase
3.Elevated level of amylase The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1. Digoxin 2.Furosemide 3.Indomethacin 4.Propranolol hydrochloride
3.Indomethacin Indomethacin is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2.Early ambulation 3.Irrigating the nasogastric tube 4.Coughing and deep-breathing exercises
3.Irrigating the nasogastric tube In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the primary health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased Paco2 2.An increased pH and a decreased Paco2 3.A decreased pH and a decreased HCO3- 4.An increased pH and an increased HCO3-
4.An increased pH and an increased HCO3- Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Notify the surgeon. 2.Measure abdominal girth. 3.Irrigate the nasogastric tube. 4.Continue to monitor the drainage.
4.Continue to monitor the drainage. Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the surgeon at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific surgeon prescriptions to do so.
Oral rifaximin has been prescribed for a client with portosystemic encephalopathy. The nurse reviews the primary health care provider's prescription and determines that this medication has been prescribed for which purpose? 1. Prevent infection. 2.Prevent restlessness in the client. 3.Prevent fluid retention and ascites. 4.Destroy normal bacteria found in the bowel.
4.Destroy normal bacteria found in the bowel. Rifaximin may be prescribed for the client with portosystemic encephalopathy. It is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. The remaining options are not accurate rationales for administration of this medication to this client.
The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? 1. Apply ice to the stoma site. 2.Apply pressure to the stoma site. 3.Notify the primary health care provider (PHCP). 4.Document the amount and characteristics of the drainage.
4.Document the amount and characteristics of the drainage. During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the PHCP is unnecessary because this is an expected finding.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high-Fowler's position during meals.
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome? 1. Diarrhea, chills, and hiccups 2.Weakness, diaphoresis, and diarrhea 3.Fever, constipation, and rectal bleeding 4.Abdominal pain, elevated temperature, and weakness
Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.
A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? 1. Sleeping 8 to 10 hours a night 2. Ability to work at home periodically 3. Eating 5 or 6 small meals per day 4. Frequent need to work overtime on short notice
Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. Of the items listed, the frequent need to work overtime on short notice is potentially the most stressful because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and a proper dietary pattern (options 1 and 3) should alleviate symptoms, not worsen them.
A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? 1. Suction the client through the endotracheal tube. 2.Instruct the client in the use of an incentive spirometer. 3.Turn the client from a 30-degree lateral position to a supine position. 4.Instruct the client to use a communication board to tell the nurse what is wrong.
The client is choking on his secretions, which should be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing his airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.
The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1. Jaundice 2.Flu-like symptoms 3.Clay-colored stools 4.Elevated bilirubin levels 5.Dark or tea-colored urine
There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flu-like symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.
The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication? 1. Bleeding 2.Infection 3.Dehydration 4.Malnutrition
Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes.
The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? 1. Hypercalcemia 2.Hypernatremia 3.Frothy, fatty stools 4.Decreased hemoglobin
Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims' position 2.Right Sims' position 3.On the left side of the body, with the head of the bed elevated 45 degrees 4.On the right side of the body, with the head of the bed elevated 45 degrees
1. Left Sims' position For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 3.Give small, frequent high-calorie feedings. 4.Maintain the client in a supine and flat position. 5.Give hydromorphone intravenously as prescribed for pain. 6.Maintain intravenous fluids at 10 mL/hour to keep the vein open.
1. Maintain NPO (nothing by mouth) status. 2.Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as prescribed for pain. The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1. Oranges 2.Broccoli 3.Margarine 4.Cream cheese 5.Luncheon meats 6.Broiled haddock
3.Margarine 4.Cream cheese 5.Luncheon meats Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.
The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply. 1.Select foods high in protein content. 2.Consume multiple small meals throughout the day. 3.Select foods low in carbohydrates to prevent nausea. 4.Allow the client to select foods that are most appealing. 5.Eliminate fatty foods from the meal trays until nausea subsides. 6.Eat a nutritious dinner because it is typically the best tolerated meal of the day.
2.Consume multiple small meals throughout the day. 4.Allow the client to select foods that are most appealing. 5.Eliminate fatty foods from the meal trays until nausea subsides. Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.
The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1. Evaluating for asterixis 2.Inspecting for petechiae 3.Palpating for peripheral edema 4.Evaluating for decreased level of consciousness
3.Palpating for peripheral edema Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.
During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? 1. Increase potassium in the diet. 2.Include rice and bananas in the diet. 3.Increase fluid and dietary fiber intake. 4.Increase the intake of sugar-free products.
3.Increase fluid and dietary fiber intake. Increase of fluid intake and dietary fiber will help change the consistency of the stool, making it easier to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not assist in alleviating constipation.
The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the primary health care provider prescribing? 1. Enteral feedings 2.Fluid restrictions 3.Oral corticosteroids 4.Activity restrictions
Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? 1. "I should increase the fiber in my diet." 2."I will need to avoid caffeinated beverages." 3."I'm going to learn some stress reduction techniques." 4."I can have exacerbations and remissions with Crohn's disease."
Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
Lactulose is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse should determine that this medication is effective if serum diagnostics reveal which finding? 1. Increased protein level 2. Increased red blood cell count 3. Decreased serum ammonia level 4. Decreased white blood cell count
Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.
The adult client with hepatic encephalopathy has a serum ammonia level of 200 mcg/dL (120 mcmol/L) and receives treatment with lactulose. The nurse determines that the client had the bestand most realistic response if the serum ammonia level changed to which value after medication administration? 1. 5 mcg/dL (3 mcmol/L) 2. 10 mcg/dL (6 mcmol/L) 3. 15 mcg/dL (9 mcmol/L) 4. 90 mcg/dL (54 mcmol/L)
The normal serum ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). In the client with hepatic encephalopathy, the ammonia level is not likely to drop below normal, nor is it likely to drop into the low-normal range. A level of 90 mcg/dL (54 mcmol/L) is slightly above normal and represents the most realistic response of the medication. The nurse should also monitor the client for signs and symptoms that indicate improvement in the condition.
A client with a history of gastric ulcers complains of a sudden, sharp, and severe pain in the midepigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and board-like on palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse suspects which condition and should perform which action? 1. Obstruction; call the operating room. 2.Perforation; notify the primary health care provider. 3.Intractability; administer cleansing enema. 4.Hemorrhage; increase intravenous fluid rate.
The signs and symptoms described in the question are consistent with perforation of the ulcer, which may progress to peritonitis if the perforation is large enough. A client with intestinal obstruction would most likely complain of abdominal pain and distention and nausea and vomiting. Intractability is a term that refers to continued manifestations of a disease process despite ongoing medical treatment. A client with hemorrhage would vomit blood or coffee-ground material or would expel black, tarry, or bloody stools.
