Archer GI

The nurse is giving discharge instructions regarding methods that can prevent dumping syndrome for a client that had undergone a pyloroplasty. Which statement from the client indicates a need for further teaching by the nurse? A. "This means I have to give up milk and cookies for my snack." B. "I need to minimize eating pasta, rice, and bread." C. "I have to stay upright after eating my meals." D. "I need to get used to eating smaller, more frequent meals." Submit Answer

Choice C is correct. To prevent rapid gastric emptying, the client needs to lie down after meals. Staying upright promotes gastric emptying due to gravity. Choice A is incorrect. To prevent dumping syndrome, the client needs to avoid sugar, salt, and milk as these promote gastric emptying. Choice B is incorrect. The client is instructed to eat a high protein, high fat, low carbohydrate diet. Pasta, rice, and bread are high carbohydrate foods that the client needs to eliminate from her diet. Choice D is incorrect. To prevent dumping syndrome, clients are instructed to eat small meals and avoid consuming fluids with meals. Last Updated - 08, May 2022

Which of the following foods eaten by a patient with an ileostomy is most likely to have caused diarrhea? A. Coffee B. Garlic C. Eggs D. Fish

Explanation Choice A is correct. Because food and fluid do not go through the large intestine, the normal process of absorbing the liquid part of stool does not occur for patients with an ileostomy. An ileostomy produces fluid fecal drainage. Drainage is constant and cannot be regulated. One nursing intervention for clients with an ileostomy is to educate them on what foods may cause stress or irritation (such as more frequent stools). Foods or drinks that are caffeinated and liquids that are high in fat, such as regular milk, should be limited to 1 cup per day to help decrease episodes of diarrhea. Choices B, C, and D are incorrect. Each of these foods may cause a stronger odor, but are not the most likely to cause diarrhea. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential, Bowel Diversion Ostomies Last Updated - 30, Sep 2021

The nurse is caring for a critically ill client receiving enteral nutrition through a nasogastric tube. Before initiating the next bolus feed, the nurse checks the residual and notes 225 mL of bright green fluid. Which actions by the nurse are appropriate? Select all that apply. A. Auscultate for bowel sounds B. Document the residual C. Discard the residual D. Do not administer the tube feeding

Explanation Choices A and B are correct. ( Choice A) Generally, residuals over 150 mL are considered above-normal volumes, although there is no need to withhold feeding for gastric residual volume (GRV) less than 500ml. The nurse should auscultate bowel sounds to detect potential signs of delayed gastric emptying in a patient with a large residual. According to a research study, the gastric emptying delay is classified into three levels based on the amount of residual volume - an amount of more than 150mL up to 250 mL is considered a mild delay. In contrast, amounts greater than 350 mL are classified as a severe delay. Per the American Society of Parenteral and Enteral Nutrition (ASPEN) and many other critical care society guidelines, the nurse should not hold feeding for a GRV of less than 500 mL in the absence of any clinical signs of intolerance. Therefore, the nurse should auscultate for bowel sounds and assess any nausea, emesis, or abdominal distention. Should there be any clinical signs of intolerance, the nurse should hold the feeding. When a large-volume residual is aspirated, it may indicate delayed gastric emptying. A prokinetic agent can be given to enhance gastric emptying. ( Choice B) The nurse should document the color, odor, consistency, and amount of the residual. One can remember this documentation from the mnemonic COCA: color, odor, consistency, and amount. For example, the nurse can document the aspirate as bright green, non-odorous, thin, 250 mL residual in this case. Such documentation will help establish a baseline for the client and identify changes that could indicate a concern. Choice C is incorrect. There is no information regarding feeding intolerance in the question stem. In the absence of feeding intolerance, the nurse should not discard the residual if it is less than 250 ml. Residuals up to 250 mL can be safely returned to the client. The nurse has aspirated stomach contents rich in electrolytes such as potassium and chloride. If the nurse discards the residual, the electrolytes will be lost, potentially exacerbating the imbalance. Choice D is incorrect. Guidelines recommend holding tube feeding only when the residual is greater than 500 mL or in the presence of any clinical signs of feeding intolerance. It is premature not to administer tube feeding without auscultating the bowel sounds and checking for signs of intolerance. If there are no signs of intolerance, the nurse should return this residual to the client, flush the tube with saline to ensure it remains patent, continue the tube feeding, and notify the physician. Additional Info Refer to ASPEN guidelines recommending 500 ml GRV cut-off for holding feeds - ASPEN Guidelines Refer to guidelines recommending up to 250 mL GRV be returned to the client - click here

Select the minerals that are accurately paired with major food sources. Select all that apply. A. Iodine: Seafood and table salt B. Chloride: Table salt C. Calcium: Kale and broccoli D. Phosphorus: Leafy vegetables and peas E. Sulphur: Peas and kale F. Magnesium: Seafood and citrus

Explanation Choices A, B, and C are correct. Iodine is found in seafood and table salt. Chloride is found in table salt. Calcium is found in kale and broccoli. Choice D is incorrect. Phosphorus is found in peas and dairy products, not leafy vegetables and peas. Choice E is incorrect. Sulfur is found in meat and dried fruits, not peas and kale. Choice F is incorrect. Magnesium is found in nuts and green leafy vegetables, not seafood and citrus. Last Updated - 25, Sep 2021

Which of the following patients would be the best candidates for total parenteral nutrition (TPN)? Select all that apply. A. A patient with inflammatory bowel disease who has intractable diarrhea. B. A patient with celiac disease who is not absorbing nutrients. C. A patient who is underweight and needs short-term nutritional support. D. A patient who is comatose and needs long-term nutritional support. E. A patient who has anorexia and refuses to take foods via the oral route. F. A patient with burns who has not been able to eat adequately for 6 days.

Explanation Choices A, B, and F are correct. The assessment criteria used to determine the need for total parenteral nutrition (TPN) include an inability to achieve or maintain enteral access. Examples include motility disorders, intractable diarrhea (Choice A), impaired absorption of nutrients from the gastrointestinal tract (Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient's response to surgery. TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections. Choice C is incorrect. For short-term use (less than four weeks), a nasogastric or gastrointestinal route is usually selected. Choice D is incorrect. A gastrostomy is a preferred route to deliver enteral nutrition in a comatose patient because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Choice E is incorrect. Patients who refuse to take food should not be force-fed nutrients against their will. NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation; Providing Parenteral Nutrition

The nurse is teaching a new graduate about nutrition screening and assessment for a newly admitted client with chronic obstructive pulmonary disease (COPD). He weighs 150 lbs but reports unintentional weight loss of 18 lbs in the last six months. Which of the following statements by the nurse indicates the further need for teaching? Select all that apply. A. "Client's weight loss indicates he is at risk of malnutrition." B. "Client's COPD by itself does not put him at risk of malnutrition." C. "Client's labs including serum albumin are needed for full nutritional assessment." D. "Fluid accumulation is one of the criteria in diagnosing malnutrition." E. "Client's mid-arm circumference is a good indicator of muscle mass."

Explanation Choices B and C are correct. These statements by the new nurse are not exact and indicate a need for additional teaching. Choice B (Client's COPD by itself does not put him "at-risk" of malnutrition) is not a valid statement by the new nurse and needs further teaching. Any chronic disease significantly increases the risk of malnutrition. Malnutrition is seen in about 35% of patients with COPD and is associated with poor outcomes and more extended hospitalization. Identifying these patients at the time of admission provides for addressing their nutritional needs appropriately. A nurse must be aware of nutrition screening to identify at-risk patients, components of nutritional assessment, and criteria for diagnosing malnutrition. Nutrition screening: must be performed for all hospitalized patients within 24 hours of admission. The purpose of this is to identify those who are malnourished or at risk of malnutrition. If the client is found to be "at-risk," a detailed nutrition assessment should then be undertaken. Adult clients with any of the following are considered "at-risk" for malnutrition: Unintentional weight loss of 10% or more within six months (Choice A) Unintentional weight loss of 5% or more within one month Unintentional weight loss or gain of 10 lb within six months Chronic disease (i.e. COPD, Ulcerative colitis) Inadequate nutrient intake (not receiving food for more than seven days) BMI (body mass index) below 18.5 kg/m2 or above 25 kg/m2. Alteration in dietary intake or dietary schedule Increased metabolic requirements (i.e. COPD, Hyperthyroidism) Nutrition assessment: Once the patient is determined to be "at-risk" for malnutrition, a detailed nutritional assessment must be carried out. This comprehensive assessment may incorporate: Information from patient history (weight-loss or weight-gain history, medication history, nutrition history, chronic disease history). Physical exam findings such as trouble chewing, swallowing disorders, hand-grip strength, skin integrity, fluid accumulation such as edema/ascites. Anthropometric measurements such as height and weight measurement, body mass index, measurements limb circumferences, and skin folds. Diagnosis of malnutrition: In 2009, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) set six criteria to diagnose malnutrition in adults. The presence of two or more of the below mentioned six characteristics is diagnostic of Malnutrition: According to ASPEN's evidence-based analysis, serum albumin and pre-albumin are not included as defining criteria of malnutrition (Choice C). This is because the serum albumin may not genuinely indicate nutritional status, but rather indicate the severity of current illness and chronic illness. It must be noted that no laboratory test is both sensitive to and specific for protein-calorie malnutrition. Therefore, Choice C (Client's serum albumin is needed for full nutritional assessment) is not a valid statement by the new nurse and needs further teaching. In monitoring nutritional outcomes for patients on total parenteral nutrition (TPN), pre-albumin and albumin can be used - this is not for initial assessment but for tracking whether the client is responding to TPN. Choices A, D, and E are incorrect. These are true statements and reflect correct understanding by the new nurse. The client lost 10% weight in the last six months, which puts him at risk for malnutrition (Choice A). The mid-arm circumference is indeed an excellent indicator of muscle mass (Choice D). Fluid accumulation such as pedal edema, ascites, and anasarca is one of the six criteria proposed by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to diagnose malnutrition. NCSBN Client Need Topic: Basic Care and Comfort; Sub-Topic: Nutrition and Oral hydration Last Updated - 13, Nov 2021

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? Select all that apply. A. Leafy greens B. Garlic C. Nuts D. Butter E. Turkey

Explanation Choices B, C, and E are correct. B is correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. C is correct. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. E is correct. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI). Choice A is incorrect. While leafy greens are good choices for many vitamins and minerals, they do not contain a lot of phosphorus. Therefore, this would not be a good choice to recommend to a client that needs a diet rich in phosphorus. Choice D is incorrect. Butter does not have a lot of phosphorus. This would not be an appropriate recommendation.

While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention? A. "The pain doesn't feel as bad now. I think it was just a stomach ache." B. "Would you mind getting me an ice pack?" C. "I know I'm not supposed to eat anything right now, but I'm hungry." D. "I wonder if I can play in the basketball game on Monday."

Explanation Choice A is correct. A patient who is suspected of having appendicitis who suddenly feels better has likely experienced a rupture of the appendix. This situation warrants immediate attention, as surgery will be necessary. Choices B, C, and D are incorrect. The patient may want an ice pack because he feels like it will ease his pain. Stating that he feels hungry is not an example of non-compliance, nor is it an emergency. Wondering if he can play basketball is not a reason for concern. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Appendicitis Additional Info

Your client has just had a fecal diversion surgery and is going to be discharged to their home. Which type of social support person or support network is most likely to be beneficial to this client in terms of their self-care and the physical adaptations which are necessary for this client? A. A peer support network like an ostomy group in the community to promote self care. B. An emotional support person to help the client cope with the altered bodily image. C. An instrumental support network to help with activities of daily living. D. A church group of volunteers who can drive the client to their doctors.

Explanation Choice A is correct. A peer support network like an ostomy group in the community to promote self-care is most likely to be beneficial to this client in terms of the care and physical adaptations necessary for this client in the community after a discharge post fecal diversion surgery. Peer support groups offer clients practical and useful ways to physically adapt to changes and to enhance their self-care skills secondary to their disease or disorder. The four types of social support systems include informational, emotional, instrumental, and appraisal support systems. A peer support group, like an ostomy group in the community, which helps the client to physically adapt to changes and to enhance their self-care skills secondary to their fecal diversion surgery is an example of an information support system. Choice B is incorrect. An emotional support person to help the client cope with the altered bodily image is indicated when the person has emotional needs, however, a person who has the need to promote their self-care needs will benefit from an informational, rather than an emotional, support person or group. The four types of social support systems include informational, emotional, instrumental, and appraisal support systems. Choice C is incorrect. A support network to help with activities of daily living is an instrumental support network. The four types of social support systems include informational, emotional, instrumental, and appraisal support systems. Choice D is incorrect. A church group of volunteers who can drive the client to their doctors' appointment are a support network that can help the client with tangible help such as transportation and help with housekeeping, but it is not one that can benefit the client in terms of the care and physical adaptations necessary for this client in the community after a discharge post fecal diversion surgery. The four types of social support systems include informational, emotional, instrumental, and appraisal support systems. Last Updated - 11, Feb 2022

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)? A. Alprazolam B. Rifaximin C. Lactulose D. Spironolactone

Explanation Choice A is correct. Benzodiazepines should be avoided for a client with hepatic encephalopathy. These medications can worsen the sensorium of a client, therefore, making the client at high risk for falls and injury. Choices B, C, and D are incorrect. Rifaximin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is the main staple in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Spironolactone is the diuretic of choice for a client's ascites because it removes the fluid but holds on to the potassium. Hypokalemia should be avoided because it contributes to the production of ammonia. NCLEX Category: Pharmacological and Parenteral Therapies Activity Statement: Adverse Effects/Contraindications/Side Effects/Interactions Question type: Knowledge/comprehension Additional Info Safe client care is emphasized when caring for a client with hepatic encephalopathy. This involves aggressive fall precautions, frequent reorientation, and administering prescribed medications. Frequent neurological assessments should be completed to determine the improvement or worsening of the client's mentation and overall function. Last Updated - 28, Apr 2022

A patient with cholecystitis is reporting acute pain. Where should the nurse expect to find the location of this pain? A. Right upper quadrant, radiating to the right shoulder B. Right upper quadrant, radiating to the left shoulder C. Right lower quadrant, radiating to the pelvic bones D. Right lower quadrant, radiating to the umbilicus

Explanation Choice A is correct. Cholecystitis is known to be painful in the right upper quadrant and refers to the right shoulder and scapula. A referred pain is a pain that is felt away from the originating site. Visceral pain can be referred to a corresponding somatic structure and is mediated by similar segmental innervation of the originating visceral organ and the referred somatic site. Choice B is incorrect. Right upper quadrant pain never radiates to the left shoulder. A left upper quadrant pain may radiate to the left shoulder and such a referred pain may be noticed with splenic injury. Choice C is incorrect. A right lower quadrant pain radiates to the pelvic bones. A right lower quadrant pain radiating to pelvic bones may be noticed with ovarian torsion. Choice D is incorrect. A right lower quadrant pain radiating to the umbilicus may be seen with acute appendicitis, not cholecystitis. NCSBN client need Topic: Physiological Integrity, Physiological Adaptation Last Updated - 13, Jan 2022

While teaching a client who has recently begun a vegan diet, the nurse should highly recommend supplementing with which of the following vitamins? A. Vitamin C B. Vitamin B12 C. Vitamin A D. Vitamin D

Explanation Choice B is correct. Vitamin B12 is abundantly present in food products of animal origin. These include eggs, poultry, dairy products, fish, and meat. No strict vegetarian source has sufficient vitamin B12 to meet the recommended daily allowance (RDA). Vegans refrain from consuming all animal products, including eggs and dairy. Therefore, vegans are at a very high risk of developing vitamin B12 deficiency. Vegans should be counseled to consume alternative sources of vitamin B12 such as vitamin B12 supplements foods fortified with vitamin B12 ( fortified nutritional yeasts, fortified cereals) to reduce the risk of B12 deficiency significantly. Choices A, C, and D are incorrect. Vegans are generally not more prone to vitamin A and C deficiencies than non-vegans. Vegans consume plenty of fruits and vegetables. Vitamin A ( Choice C) is present abundantly in carrots, apricots, sweet potatoes, and dark green leafy vegetables ( spinach, kale, and collard greens). Vitamin C ( Choice A) is present abundantly in fruits ( orange, apple, kiwi, etc.) and vegetables ( bell peppers, brussel sprouts, broccoli, and so on). While vitamin D ( Choice D) is not abundant in a vegan diet, there are still some good vegan sources, including mushrooms, spinach, and bananas. Also, vitamin D can be abundantly obtained from sunlight. Vegans may be more prone to vitamin D deficiency than non-vegans. However, the vegans' highest risk is for vitamin b12 deficiency, and the nurse should prioritize this recommendation. NCSBN client need Topic: Basic Care and Comfort: Nutritional Learning Objective Recognize that strict vegans are prone to significant vitamin B12 deficiency. Vegans should be counseled to consume alternative B12 resources. Additional Info Vitamin B12 deficiency can lead to fatigue, dementia, glossitis ( tongue inflammation), macrocytic anemia ( anemia with large red blood cells), pancytopenia ( reduced blood counts along all cell lines, i.e., reduced red cells, white blood cells, and platelets ), and neurological manifestations ( neuropathy, paresthesias. tingling and numbness in extremities). Vitamin B12 is abundantly stored in the body (up to 1000 times recommended daily allowance). Therefore, it generally takes several years of suboptimal b12 intake or poor absorption for vitamin B12 deficiency to develop. The population at risk for vitamin B12 deficiency include:\ Vegans who consume no animal or dairy products. Exclusively breastfed infants of vegan women. Clients with vitamin b12 malabsorptive conditions ( pernicious anemia, celiac disease, Crohn's disease) Clients with gastric bypass surgery or other surgeries where the stomach is removed. Older adults Long term use of proton pump inhibitors Long term use of metformin

The nurse is teaching a 57-year-old client about screening for colorectal cancer. Which of the following information should the nurse include? A. "It is recommended that colon cancer screening with a colonoscopy should begin at age 45." B. "It is recommended that colon cancer screening with a colonoscopy should begin at age 70." C. "It is recommended that colon cancer screening with a colonoscopy should begin at age 40." D. "It is recommended that colon cancer screening with a colonoscopy should begin at age 65." Submit Answer

Choice A is correct. The nurse should inform the client that colonoscopy should begin at age 45. Current screening guidelines state that colon cancer screening with a colonoscopy should begin at age 45 unless known risk factors are present. Choices B, C, and D are incorrect. Certain clients with high-risk conditions (ulcerative colitis, lynch syndrome, family history of colon cancer) may develop colon cancer early. For these individuals, recommendations vary. There is no indication that the client in the vignette has a family history or high-risk predisposing condition. Additional Information - The majority of colon cancer cases occur in patients aged 50 or older. The United States Preventive Task Force (USPTF) recommends initiating colon cancer screening at 45. The idea of colon cancer screening with colonoscopy is to detect precancerous polyps and remove them before they have had a chance to turn malignant. For those who refuse colonoscopy or cannot undergo colonoscopy, an alternative option is fecal occult blood testing (FOBT) and flexible sigmoidoscopy together. Counseling the client about colon cancer and recommending measures to prevent it (such as adopting a high-fiber diet) is primary prevention. Screening for colon cancer is a form of secondary prevention. NCLEX Category: Health promotion and maintenance Related Content: Health screening Question type: Knowledge/comprehension Last Updated - 29, Mar 2022

A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. In educating the client regarding this drug's mechanism of action, the nurse would be most accurate in informing the client that this medication: A. Decreases gas formation B. Increases the speed of gastric emptying C. Lines the stomach for protection D. Increases the lower esophageal sphincter pressure Submit Answer

Choice C is correct. Misoprostol is a synthetic prostaglandin that protects the gastric mucosa by decreasing gastric acid secretion and lining the stomach for protection by increasing mucus and bicarbonate secretion. Misoprostol reduces the risk of NSAID-induced gastric ulcers, as NSAIDs decrease prostaglandin production and predispose the client to peptic ulceration. Choice A is incorrect. Misoprostol does not decrease gas formation in clients taking the medication. Choice B is incorrect. Client taking misoprostol do not experience an increased speed of gastric emptying. Choice D is incorrect. Misoprostol does not increase the lower esophageal sphincter pressure in clients taking the medication. Learning Objective The nurse would be most accurate in informing the client that misoprostol works by lining the stomach for protection and decreasing gastric acid secretion. Additional Info Misoprostol is a synthetic prostaglandin E1 analog that stimulates prostaglandin E1 receptors on parietal cells. Mucus and bicarbonate secretion are also increased along with thickening of the mucosal bilayer so the mucosa can generate new cells. Women of childbearing age should not use misoprostol. Avoid taking magnesium-containing antacids while using misoprostol.

The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply. A. "I will not be able to eat or drink anything for six to eight hours before this procedure." B. "I will have to do a bowel prep before this procedure." C. "Someone will have to drive me home after this procedure." D. "I should expect that I will have abdominal pain and distention for one or two days following this procedure." E. "I can expect to have white stools one to two days following this procedure."

Choices B, D, and E are correct. Bowel prep would be required for a barium enema or a colonoscopy. Abdominal pain and distention one to two days following this procedure requires follow-up as post-procedure pancreatitis may adversely occur. This complication has deterred many providers from pursuing this procedure. Choices A and C are incorrect. These statements are factual and do not require follow-up. To prevent aspiration, the client will have nothing by mouth status (NPO) six to eight hours before this procedure. This procedure involves the client being moderately sedated with medications such as lorazepam, propofol, midazolam, or fentanyl. The residual sedation puts the client at risk for a motor vehicle accident. Thus, the client must not drive following this procedure. Additional Info Endoscopic retrograde cholangiopancreatography (ERCP) has a procedure that has lost popularity in the years because of the risk of post-procedure pancreatitis. This procedure aims to examine the biliary tree for obstruction or inflammation. ➢ This procedure involves moderate sedation, which requires the client to be NPO for six to eight hours prior to the procedure ➢ The client may be repositioned during this procedure to enhance the visualization of the structures ➢ Abdominal cramping immediately following this procedure is likely because of the gastric insufflation of carbon dioxide ➢ The client should be educated on any signs of pancreatitis, which includes nausea, vomiting, and/or abdominal pain ➢ Other complications include infection, bleeding, or perforation

Which of the following most impacts the client's food preferences? A. Culture and cultural background B. The frequency of grocery shopping C. The availability of foods locally D. The costs associated with food

Explanation Choice A is correct. Culture and cultural background have the most impact on the client's food preferences. Other factors that impact the client's food preferences include religious practices, age, level of development, and also one's taste preferences (likes and dislikes). Although the frequency of grocery shopping, the availability of foods locally, and the costs associated with food impact the client's access to as well as affordability of cooking, these factors do not impact the client's food preferences of likes and dislikes. Choice B is incorrect. The frequency of grocery shopping and the client's access to foods (mainly fresh fruits and vegetables) impact the client's availability of fares. This frequency does not impact the client's food preferences of likes and dislikes. Choice C is incorrect. The availability of foods locally (mainly fresh fruits and vegetables) impacts the client's availability of fares. This frequency does not impact the client's food preferences of likes and dislikes. Choice D is incorrect. The costs associated with food impact the client's access and affordability of foods, but these factors do not impact the client's food preferences of likes and dislikes. Last Updated - 01, Aug 2021

The nurse observes a patient clutching her abdomen and complaining of cramping, which is accompanied by sharp pain. Which of the following types of pain is the client experiencing? A. Cutaneous or superficial somatic B. Visceral C. Deep somatic D. Radiating

Explanation Choice A is correct. Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing "sharp" pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the patient as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue). Choice B is incorrect. Visceral pain is caused by the stimulation of deep internal pain receptors. It is most often experienced in the internal organs of the abdominal cavity, skull, or thorax. Visceral pain is not well localized and can be described as tight, pressure, deep squeezing, or aching pain. Choice C is incorrect. Deep somatic pain originates in the ligaments, tendons, nerves, blood vessels, and bones. It is localized and can be described as achy or tender. A fracture or sprain, arthritis, and bone cancer can cause deep bodily pain. Choice D is incorrect. Radiating pain starts at the origin but extends to other locations. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Basic Care & Comfort Last Updated - 06, Feb 2022

This nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following findings would indicate a therapeutic response? A. Decreased abdominal cramping B. Absence of nausea and vomiting C. Decreased urinary retention D. Less burning with urination

Explanation Choice A is correct. Dicyclomine is an antispasmodic agent used in the treatment of irritable bowel syndrome (IBS). This may provide the client with relief from the spasms and cramping associated with IBS. Choices B, C, and D are incorrect. Dicyclomine is not indicated for the treatment of nausea, vomiting, urinary retention, or dysuria. This medication has anticholinergic properties and may cause dizziness, xerostomia, nausea, and/or blurred vision. Additional Info Dicyclomine is typically dosed on a PRN basis for a client experiencing abdominal cramping. This medication is antispasmodic and is often utilized for irritable bowel syndrome (IBS). The client should be educated on the common adverse effect of dizziness which may increase a client's risk for falls. Last Updated - 15, Feb 2022

The RN is caring for a 72-year-old patient on the medical-surgical floor. Which of the following factors would not be an indication for this patient to receive parenteral nutrition? A. Dysphagia B. Gastrointestinal obstruction C. Severe anorexia nervosa D. Severe burns

Explanation Choice A is correct. Dysphagia indicates an inability to swallow. Parenteral nutrition aims to meet the body's need for nutrients via a route other than the GI tract (i.e. bloodstream) and is indicated when the GI tract is unable to ingest, digest, or absorb nutrients. A patient who is unable to swallow may require an alternate form of nutrient delivery, such as enteral nutrition, but this would not necessarily be an indication for parenteral nutrition. Choice B is incorrect. A gastrointestinal obstruction would interfere with the GI tract's ability to ingest, digest, and absorb nutrients, so this is a common indication for parenteral nutrition. Choice C is incorrect. Severe anorexia nervosa would interfere with the GI tract's ability to ingest, digest, and absorb nutrients, so this is a common indication for parenteral nutrition. Choice D is incorrect. Severe burns or trauma can put a greater demand on the body for nutrients than what can safely be consumed via the GI system. Parenteral nutrition may be indicated to supplement the additional nutrients without overloading the GI system with excessive caloric volume. Last Updated - 14, Feb 2022

The nurse is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include? A. Pneumatic compression devices B. Insertion of an indwelling urinary catheter C. Strict bed rest D. Measure the abdominal girth

Explanation Choice A is correct. Following bariatric surgery, the client faces various complications, including hemorrhage, wound disruption, pneumonia, and infection. Venous thromboembolism is a significant complication and may be mitigated using pneumatic compression devices as well as chemical prophylaxis. Choices B, C, and D are incorrect. Insertion of a urinary catheter is not standard of care for a client recovering from bariatric surgery. This could cause bacterial cystitis, which may complicate healing. Strict bed rest is not recommended because this increases the risk for pneumonia and venous thromboembolism. Patients are often expected to ambulate several hours after surgery. Measuring the abdominal girth is an intervention for a client with ascites and is not applicable to those who have undergone bariatric surgery. Additional Info Bariatric surgery is major surgery with many complications such as venous thromboembolism, nutritional deficiencies, dumping syndrome, pneumonia, and infection. Venous thromboembolism may be mitigated by early ambulation, compression devices, and chemical prophylaxis. It is common for those who have undergone this surgery to ambulate within six to eight hours post-operatively to prevent such complications. Last Updated - 21, Aug 2022

A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting? Correct A. Intermittent suction at 70 mmHg B. Intermittent suction at 100 mmHg C. Continuous suction at 100 mmHg D. Continuous suction at 70 mmHg

Explanation Choice A is correct. Gastric decompression should always be intermittent and at low suction pressure. A suction pressure below 80 mmHg is considered low suction. Choices B, C, and D are incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration. Last Updated - 15, Feb 2022

A patient presents with enlarged tonsillar nodes. Acutely infected nodes would be: A. Firm but movable and tender B. Hard and nontender C. Fixed and soft D. Irregular and hard

Explanation Choice A is correct. Infected lymph nodes are usually tender. Choice B is incorrect. Infected lymph nodes are usually tender. Choice C is incorrect. Lymph nodes are movable. Choice D is incorrect. Lymph nodes are usually not irregular in shape. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Nose, Sinuses, Mouth, and Throat Last Updated - 02, Jan 2022

A post-hemorrhoidectomy client is preparing for discharge to home. During the provision of discharge instructions, the nurse should highlight which of the following points? A. The proper technique for sitz bath B. Restricting fluid intake for 24 hours C. Laxative administration upon discharge D. Lying in a recumbent position Submit Answer

Explanation Choice A is correct. It is important that the client is instructed to perform a sitz bath appropriately, understanding that the operative site must be exposed to the warm, moist heat during each sitz bath. Specifically, the nurse should educate the client to perform sitz baths three to four times daily in the immediate post-operative period following a hemorrhoidectomy. Choice B is incorrect. There is no indication that this client should be placed on a fluid restriction for 24 hours, nor should such information be part of the client's discharge instructions. The National Academy of Medicine suggests an adequate intake of daily fluids of roughly 13 cups (104 ounces) for healthy men and 9 cups (72 ounces) for healthy women. Choice C is incorrect. Stool softeners are more likely to be prescribed for use upon discharge than laxatives, as laxatives are more likely to cause diarrhea and cause increased pain in the rectal region. Choice D is incorrect. The client would not be instructed to lie in a recumbent position upon discharge, as this position would pressure the surgical site. Conversely, the client would be encouraged to rest in a side-lying position, as this would reduce pressure on the surgical site and likely aid in preventing or minimizing discomfort. Learning Objective When preparing a post-hemorrhoidectomy client for discharge to home, recognize the need to focus discharge teaching on the proper technique for a sitz bath. Additional Info A client who has undergone rectal surgery (including a post-hemorrhoidectomy client) benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The client sits in a special tub or chair or a basin that fits on the toilet seat, so the legs and feet remain out of the water. Submerging the entire body induces widespread vasodilation and nullifies the effect of local heat application to the pelvic region. The selected temperature for a sitz bath depends on the desired outcome: relaxation or wound cleansing. To maintain a constant temperature, warm or cool water may be added during the procedure, typically lasting approximately 20 minutes. Disposable sitz bath basins are also available and generally contain an attachment resembling an enema bag to allow the gradual introduction of additional water.

The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)? A. Muscle rigidity of the neck B. Hyperactive bowel sounds C. Frequent diarrhea D. Abdominal distention

Explanation Choice A is correct. Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning. Choices B, C, and D are incorrect. Metoclopramide increases gastric motility and may therapeutically treat gastroparesis. Hyperactive bowel sounds and frequent diarrhea may occur because of increased gastric motility. However, these findings are not concerning because they are expected with this medication. Abdominal distention is a characteristic of gastroparesis and would not be reported to the PHCP. Additional Info Gastroparesis is a finding associated with various conditions, including diabetes mellitus. This disorder causes the client to have abdominal fullness, nausea, vomiting, and weight loss. Treatment is aimed at increasing gastrointestinal motility by using agents such as metoclopramide or erythromycin. Dystonic reactions adversely occurring with metoclopramide may be treated with diphenhydramine or benztropine.

The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order? A. Vitamin B12 B. Metoclopramide C. Sucralfate D. Hydroxyzine

Explanation Choice A is correct. Procedures like a gastrectomy put the client at risk for pernicious anemia (B12 deficiency). It is quite common for a client to receive parenteral B12 replacement indefinitely. Choices B, C, and D are incorrect. Sucralfate is a gastric protectant that coats certain gastrointestinal tract ulcers. There is no indication that a client would need this medication following this surgery. Metoclopramide is a gastric emptier indicated for nausea and vomiting. Hydroxyzine is an anticholinergic indicated in treating anxiety disorders and seasonal allergies. Additional Info Classic manifestations of vitamin B12 anemia include cognitive slowing, numbness and tingling in the extremities, glossitis, insomnia, and irritability. This macrocytic anemia caused by a gastrectomy is treated with parenteral vitamin B12 injections. Last Updated - 05, Dec 2022

The nurse is caring for a client who reports excessive flatulence and abdominal cramping. The nurse anticipates a prescription for A. simethicone. B. omeprazole. C. ferrous sulfate. D. cimetidine.

Explanation Choice A is correct. Simethicone is intended to treat excessive flatulence and its discomforts. The drug works by releasing the gas via the mouth or rectum, thus, relieving the cramping sensation. Choices B, C, and D are incorrect. Omeprazole is a proton pump inhibitor indicated in the management of GERD and peptic ulcer disease. Ferrous sulfate is iron and is indicated in the management of iron deficiency anemia. Cimetidine is a medication indicated in the treatment of GERD as well. It is an H2 blocker and works by blocking the histamine receptors in the stomach, therefore, decreasing the secretion of gastric acid. Additional Info For a client with flatulence, another measure they may take is limiting the amount of gas-forming foods such as legumes (beans) and cruciferous vegetables (e.g., cauliflower, broccoli). Last Updated - 03, Aug 2022

Which of the following regions is known as McBurney's point? See the exhibit.

Explanation Choice C is correct. The RLQ (Right Lower Quadrant) of the abdomen is where McBurney's point is located. Pain in this region can indicate appendicitis. Choice A is incorrect. The RUQ (Right upper quadrant) of the abdomen is the location where pathologies related to the liver can be assessed, not appendicitis. Choice B is incorrect. The LUQ (Left Upper Quadrant)of the abdomen is the location of the spleen. Choice D is incorrect. The LLQ (Left Lower Quadrant) of the abdomen is the location of the sigmoid colon. Pathologies such as diverticulitis may be assessed by palpating this area.

The nurse is assessing a client receiving peritoneal dialysis. Which laboratory result should immediately be reported to the primary healthcare provider (PHCP)? A. WBC 19,000 mm3 B. Hemoglobin 9 mg/dL C. Calcium 8.6 mg/dL D. Serum pH 7.33

Explanation Choice A is correct. The biggest complication associated with peritoneal dialysis is peritonitis. Manifestations associated with peritonitis include fever, abdominal rigidity, purulent effluent, and nausea/vomiting. One of the earliest signs of peritonitis associated with peritoneal dialysis is cloudy outflow. Choices B, C, and D are incorrect. A client with chronic kidney disease will have anemia, hypocalcemia, and metabolic acidosis. These are all expected findings and do not need to be reported to the PHCP. The anemia is related to the kidney's inability to secrete erythropoietin (EPO). Hypocalcemia is linked to the inability of the kidneys to recycle vitamin D. Finally, acidosis is consistent because of the kidney's inability to regulate sodium bicarbonate. Additional Info When caring for a client performing peritoneal dialysis, it is essential to reinforce measures to reduce the risk of infection. These measures should include meticulous hand hygiene, sterile dressing at the catheter insertion site, and appropriate cleaning of the site with antibacterial soap and water. Last Updated - 03, Dec 2022

The nurse is teaching a client about prescribed metronidazole. Which of the following statements, if made by the client, would indicate effective teaching? A. "I should not drink alcohol while I'm taking metronidazole." B. "It is okay for me to be in the sun while I'm taking this medicine." C. "I should take the medicine until my stomach stops hurting, then stop." D. "I should take the medicine on an empty stomach."

Explanation Choice A is correct. The client should be advised not to take metronidazole with alcohol since mixing the two can cause abdominal pain, nausea, vomiting, and dizziness. The client should wait for three days after the prescription is complete before drinking any alcohol. Choices B, C, and D are incorrect. Metronidazole can cause photosensitivity (increased sensitivity to sunlight). The client should be advised to stay out of the sun during treatment. Since metronidazole is an antibiotic, the client should understand that the entire prescription should be taken as directed. Taking the medication with food or a full glass of milk is advisable to avoid an upset stomach. Other side effects of metronidazole include a metallic taste in the mouth, decreased appetite, diarrhea or constipation, and a darkening of the color of the urine.

The client is receiving instructions from the nurse in a clinic about interventions that help alleviate symptoms of gastroesophageal reflux disease. Which statement from the client indicates an accurate understanding of the instructions given? A. "It's much better for me to wear loose-fitting clothes right now." B. "Thank goodness, I can still eat a burger and fries." C. "A glass of wine before bedtime can help me sleep better." D. "I need to take my medication, omeprazole, after meals." Submit Answer

Explanation Choice A is correct. The client with GERD is advised to avoid tight clothing and wear loose-fitting clothing. Choice B is incorrect. The client with GERD is encouraged to eat a low-fat, high-fiber diet. Burger and fries have high-fat content and may stimulate excess gastric acid production. Choice C is incorrect. Clients are instructed to avoid eating and drinking 2 hours before bedtime; they also need to avoid alcohol. Choice D is incorrect. Omeprazole is a proton pump inhibitor; it needs to be taken 20 - 30 minutes before meals to achieve its desired effect. Last Updated - 09, Feb 2022

Your 78-year-old client has been receiving antibiotics for ten days and tells you that he is having frequent watery stools. Which action will you take first? A. Place the client on contact precautions. B. Instruct the client about correct handwashing. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.

Explanation Choice A is correct. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be to place him on contact precautions in order to prevent the spread of C. difficile to other clients. Clostridium difficile (C. difficile), a spore-forming bacillus that infects the gastrointestinal (GI) tract following treatment of other infections with antibiotics is one of the few hospital-acquired infections (HAIs) increasing in frequency. C. difficile spores are transferred to clients mainly via the hands of health care personnel who have touched a contaminated surface or item. Choices B, C, and D are incorrect. These are appropriate actions but should be taken after the client is placed on contact precautions. The other activities are also needed and should be taken after placing the client on contact precautions. NCSBN Client Need Topic: Safe and Effective Care Management, Subtopic: Safety and Infection Control Last Updated - 15, Feb 2022

A client comes to the outpatient clinic complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. What should the nurse's first action be? A. Ask the client about any recent travel to Asia or the Middle East. B. Screen clients for upper respiratory tract symptoms. C. Review the client's history of recommended immunizations. D. Call an ambulance to take the client immediately to the hospital.

Explanation Choice A is correct. The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always patient safety. This includes not only the patient the nurse is assessing but those who are present within the facility and the staff as well. Determining where a patient has been and any activities he or she has been involved with will help pinpoint the possible source of illness/infection. Choices B, C, and D are incorrect. While these actions may be appropriate, they are not the initial action to take for the client who may transmit the infection to other patients or staff. NCSBN Client Need Topic: Safe and Effective Care Environment, Subtopic: Safety and Infection Control Last Updated - 14, Feb 2022

A patient is being evaluated in the clinic for pancreatitis. Besides an elevated white blood cell count and serum lipase levels, which assessment finding indicates a positive finding for pancreatitis? A. The discoloration of the abdomen and periumbilical area B. Overactive bowel sounds C. Low bilirubin levels D. Bluish discoloration of the soles of the feet

Explanation Choice A is correct. The discoloration of the abdomen and periumbilical area is known as Cullen's sign and indicates pancreatitis when it occurs in conjunction with other symptoms. Other findings include elevated white blood cell count, bilirubin, and urinary amylase levels. Choice B is incorrect. In pancreatitis, bowel sounds are generally diminished or absent. Choice C is incorrect. Bilirubin levels are generally elevated in instances of pancreatitis. Choice D is incorrect. Bluish discoloration of the feet is not associated with pancreatitis. However, bluish discoloration of the flanks is known as Turner's sign and is used as an indicator of pancreatitis. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is taking care of a client that is scheduled to undergo a gastric analysis at 8:00 AM tomorrow. Which should be included in the client's plan of care? A. Instruct the client that she should not eat or drink anything after midnight. B. Teach the client that in case she feels hungry, she can chew some gum. C. Instruct the client that she needs to be on bed rest for 2 hours after the procedure. D. Tell the client that she is allowed to smoke 1 hour prior to surgery. Submit Answer

Explanation Choice A is correct. The gastric analysis involves the insertion of a nasogastric tube (NGT) and aspiration of gastric contents for analysis of pH, appearance, and volume. The patient needs to be on NPO (nothing by mouth) for 8 - 12 hours before the test. Choice B is incorrect. The use of tobacco and chewing gum is avoided for 6 hours before the test. Choice C is incorrect. The client can resume her normal activities right after the test and does not need to be on bed rest. Choice D is incorrect. The use of tobacco and chewing gum is avoided for 6 hours before the test. Last Updated - 11, Dec 2021

The nurse is caring for a client who is diagnosed with acute appendicitis. After several hours of pain, the client suddenly states a relief in his pain. What is the initial action of the nurse? A. Notify the physician B. Document the finding C. Insert an IV cannula D. Administer a laxative

Explanation Choice A is correct. The nurse should notify the physician immediately to assess the client and prepare for surgery since this could signify a rupture of the appendix; any delay could cause peritonitis. Choice B is incorrect. The nurse needs to document the finding, but only after necessary interventions are initiated. Choice C is incorrect. The nurse can insert an IV cannula during preparations for surgery. However, the initial action of the nurse is to notify the physician. Choice D is incorrect. The nurse should never administer a laxative, an enema, or apply heat to the abdomen since any of these can cause perforation of the bowels.

A 30-year-old male client in the medical ward was admitted for a hiatal hernia and is being discharged today. The nurse talks to him regarding methods to prevent and reduce pain associated with his condition. Which of the following statements from the client indicate that teaching is successful? A. "I need to wear loose-fitting clothes." B. "After a meal, I must lie down to avoid dumping syndrome." C. "I need to eat three large meals a day." D. "I can go to my favorite Indian restaurant anytime of the week."

Explanation Choice A is correct. The nurse should teach the client measures that reduce gastric acid reflux in the patient. The nurse should instruct the patient to wear loose-fitting clothes to prevent pressure in the stomach that might cause reflux. Choice B is incorrect. The client should not lay down after a meal. Instead, the client should remain in an upright position for 2 hours after eating. Dumping syndrome in a hiatal hernia does not exist. Choice C is incorrect. The nurse should instruct the client to have frequent small feedings rather than three large meals to avoid gastric reflux. Choice D is incorrect. Spicy food and caffeine trigger acid reflux and should be avoided. Indian food is full of spices, therefore clients should avoid eating spicy food. Last Updated - 10, Feb 2022

During shift change, a nurse receives report regarding a client with ulcerative colitis, learning the client has experienced severe diarrhea over the past 24 hours. When assessing the client, the nurse should watch for signs of: A. Metabolic acidosis B. Metabolic alkalosis C. Malnutrition D. Malabsorption

Explanation Choice A is correct. The nurse should watch for signs of metabolic acidosis, as diarrhea is one of the conditions most commonly associated with this acid-base imbalance due to bicarbonate loss occurring with diarrhea. Symptoms and signs of metabolic acidosis are primarily those of the underlying cause (i.e., here, the client's diarrhea). More severe acidemia (i.e., pH < 7.10) may cause nausea, vomiting, and malaise. Choice B is incorrect. Clients with vomiting, diuretic use, or excessive over-the-counter antacid use are at risk for metabolic alkalosis. Metabolic alkalosis occurs due to an elevation of sodium bicarbonate which leads to an increase in a client's HCO3- level. Choice C is incorrect. Malnutrition is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring. Choice D is incorrect. Malabsorption is a possible long-term complication of ulcerative colitis. This complication typically requires more than 24 hours of active symptoms before occurring. Learning Objective Recognize that when caring for a client experiencing 24 hours of diarrhea, the nurse should assess the client for signs and symptoms of metabolic acidosis. Additional Info Treatment of metabolic acidosis is based on the cause of the metabolic acidosis. Ulcerative colitis is a chronic inflammatory and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea. Extraintestinal symptoms, particularly arthritis, may occur. Long-term risk of colon cancer is elevated compared to unaffected people. Diagnosis is by colonoscopy. Treatment occurs with various medications (i.e., 5-aminosalicylic acid, corticosteroids, immunomodulators, biologics, and/or antibiotics) and surgery in some clients. Last Updated - 07, Feb 2022

A 52-year-old male client is hospitalized with mild ascites, jaundice, and bruising. He has a 20-year history of alcohol abuse. Further studies confirmed the presence of esophageal varices. A high serum ammonia level indicates that he has hepatic encephalopathy. The nurse is concerned about the esophageal varices that may rupture anytime and proceeds to educate the client and his family. Which item should the nurse include in the teaching to prevent the rupture of the varices? A. "He should not lift heavy objects." B. "He must avoid walking briskly." C. "He should avoid taking barbiturates." D. "He should avoid ingesting antacids." Submit Answer

Explanation Choice A is correct. The possibility of ruptured esophageal varices can be brought about by increasing intrathoracic pressure. Among the activities mentioned, only lifting heavy objects can predispose the client to increased intrathoracic pressure. The client should, therefore, avoid doing this. Choices B, C, and D are incorrect. These activities do not cause an increase in intrathoracic pressure. Last Updated - 04, Dec 2021

The nurse is explaining the different aspects of ostomy care to a client with a newly created ileostomy. Which statement from the client indicates an understanding of the nurse's teaching? Incorrect Correct Answer(s): A A. "I need to cut the pouch to fit the stoma, allowing one-sixteenth of an inch of room around it." B. "I must avoid eating spinach, parsley, and yogurt." C. "I need to drink at least 800 mL of water daily." D. "I can eat a large meal during dinner."

Explanation Choice A is correct. This is an accurate statement by the client. The client should be taught how to attach the pouch properly onto the stoma. The pouch should allow only 1/16 to 1/8 of an inch of room around the stoma. The client needs to understand that if the bag does not fit well, it can cause skin breakdown from contact with feces while allowing for passage of effluent through the stoma. Choice B is incorrect. The client must be encouraged to eat spinach, parsley, and yogurt, as these foods reduce drainage odor. Choice C is incorrect. The client should drink at least 2000 mL of water daily to prevent severe fluid and electrolyte imbalance as well as urolithiasis. Choice D is incorrect. It is not advisable to eat a large meal close to bedtime as ingested food passes through the ileostomy within 4-6 hours. Last Updated - 07, Feb 2022

Which nursing action is performed correctly when providing care for a newly placed gastrostomy tube of a postoperative patient? A. The nurse dips a cotton-tipped applicator into the sterile saline solution and gently cleans around the insertion site. B. The nurse wets a washcloth and washes the area around the tube with soap and water. C. The nurse adjusts the external disk every three hours to avoid crusting around the tube. D. The nurse tapes a gauze dressing over the site after cleansing it.

Explanation Choice A is correct. When caring for a new gastrostomy tube; the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. Choice B is incorrect. The nurse should not use a washcloth with soap and water on a new gastrostomy tube. This method can be used if the site is healed. Choice C is incorrect. Once sutures are moved, the external bumper can be rotated 90 degrees once daily. Choice D is incorrect. The site should be left open to air unless there is drainage. If drainage is present, one thickness of pre-cut gauze should be placed under the external bumper and changed as needed to keep the area dry. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Long-Term Nutritional Support Last Updated - 29, Jan 2022

While working in a post-operative unit, the nurse is assigned to take care of a 32-year-old who is post-op day one after an appendectomy. The patient has not eaten for the past three days and is asking when she will be allowed to have a meal again. Upon consulting with the interdisciplinary team, the provider decides it is time to place a diet order for your patient. Which diet does the nurse expect the provider will order? A. Full-liquid diet B. Clear liquid diet C. Soft diet D. Mechanical diet

Explanation Choice B is correct. A clear liquid diet is the most appropriate choice for this patient. Clear liquid diets consist of foods and liquids that are transparent to light and are liquid when at body temperature. This diet is best for patients who have not had oral intake for some time as well as for the first time a patient eats after complete bowel rest. Choice A is incorrect. A full-liquid diet is wrong. This diet is appropriate as a transition after a clear liquid diet for patients following surgery, but should not be the first diet ordered. Choice C is incorrect. A soft diet is also wrong, as this is only indicated when patients have difficulty chewing or swallowing and need foods that are much easier to eat. Choice D is incorrect. A mechanical diet is not appropriate for this patient. This diet consists of foods that have been processed so that they do not require some or any chewing. It is used for patients with dental problems, surgeries to the head and neck, or other disorders that make chewing difficult or unsafe. NCSBN Client Need: Topic: Basic Care and Comfort Subtopic: Nutrition and Oral Hydration

The nurse is caring for a client with occult blood in the stool. Which of the following medications should the nurse question? A. Iron sucrose B. Enoxaparin C. Sulcralfate D. Hydroxyurea

Explanation Choice B is correct. A client with occult blood in their stool should not have any anticoagulants until the cause may be identified. Enoxaparin is a low-molecular-weight heparin (LMWH), and the client should be monitored for gastrointestinal bleeding such as occult blood. Choices A, C, and D are incorrect. Iron may cause black tarry stools, but it does not cause gastrointestinal bleeding. Iron may also cause significant constipation. Sucralfate is a gastric mucosa protectant utilized for clients with peptic ulcer disease. This medication is given in advance of meals to prevent pain during eating. Hydroxyurea is indicated for certain cancers and sickle cell anemia; this medication does not cause occult blood in the stool. Iron sucrose, sucralfate, and hydroxyurea do not have the propensity to cause gastrointestinal bleeding. Additional Information. A gastrointestinal bleed or medications could cause occult blood in the stool. Heparinoids such as enoxaparin and heparin may adversely cause gastrointestinal bleeding. For a client taking an LMWH, assess all stools for occult blood. The aPTTs are not checked on an ongoing basis because the doses of LMWH are not routinely adjusted. Last Updated - 04, Apr 2022

The nurse is teaching a patient who is scheduled for a colonoscopy. Which of the following information should the nurse include? A. "The day before the procedure you may have a regular diet." B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." C. "You may notice chalky white stools immediately after the procedure." D. "Your abdomen will be painful and distended after the test." Submit Answer

Explanation Choice B is correct. A colonoscopy is a test used to study the lining of the large intestine. Four to six hours before the procedure. the nurse is correct to instruct the client to not intake anything by mouth (NPO). Choice A is incorrect. The day before the process, the nurse should tell the client to have a clear liquid diet. Choice C is incorrect. Chalky white stools after the procedure are expected with a barium enema - not a colonoscopy. Choice D is incorrect. Abdominal pain and distention are unlikely as this would be worrisome for a perforation. Last Updated - 26, Oct 2021

The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted? A. Narrowed and flattened B. Concave and bowl-shaped C. Dry and reddish-purple D. Pinkish-red and moist

Explanation Choice B is correct. A stoma that has retracted will appear concave and bowl-shaped. A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. Monitoring for signs of proper healing and educating the client/caregivers on signs of complicated healing is important. Complications that could arise from retracted stoma include difficulty maintaining appliance placement, which could lead to leakage and irritated skin. Choice A is incorrect. A narrow, flattened, or constricted stoma indicates stenosis. Choice C is incorrect. A dry, dusky, or reddish-purple stoma indicates ischemia. Choice D is incorrect. A healthy stoma will protrude about 2.5 cm with an open lumen at the top. It should appear pinkish-red and moist. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Fecal Elimination Last Updated - 10, Nov 2021

A patient is about to get a Salem sump NG tube inserted. Which position should the nurse place the patient in? A. Supine, with the head of the bed elevated at 30° - 45° B. Supine, with the head of the bed elevated at 60° - 90° C. Knee-chest position D. Prone position

Explanation Choice B is correct. A supine position with a 60° - 90° elevation facilitates swallowing of the patient and lets gravity help in the movement of the tube down the GI tract. Choice A is incorrect. The nurse should position the patient so that the insertion of the NG tube is facilitated. An elevation of 30° - 45° is not enough to facilitate the movement of the tube down the GI tract. Choice C is incorrect. A knee-chest position does not facilitate the movement of the tube down the GI tract. Choice D is incorrect. A prone position does not facilitate the insertion of the NG tube. Last Updated - 27, Dec 2021

A nurse is caring for a client who is currently being weaned from total parenteral nutrition (TPN) and is expected to begin receiving oral intake today. Currently, the TPN solution is infusing at 100 mL/hr. When the health care provider (HCP) writes the order for oral diet, which of the following orders should the nurse anticipate being included? A. Discontinue the TPN. B. Decrease the rate of the TPN infusion by 25 mL/hr every two hours until no longer infusing. C. Start 0.9% normal saline at a rate of 30 mL/hr. D. Maintain the current TPN infusion order.

Explanation Choice B is correct. Abrupt discontinuation of total parenteral nutrition (TPN) may lead to severe hypoglycemia, and for this reason, the infusion must be decreased gradually. Additionally, the client should have glucose assessments performed at intervals specified by the health care provider (HCP) both during the weaning of the TPN and in the immediate aftermath of the weaning process. Choice A is incorrect. Abruptly discontinuing the infusion of TPN could lead to severe hypoglycemia and should therefore be avoided. Choice C is incorrect. Initiating an infusion of 0.9% normal saline is not appropriate, as this IV solution does not contain any glucose to counteract the potential severe hypoglycemia resulting from the abrupt TPN discontinuation. Choice D is incorrect. Maintaining the current TPN infusion order while initiating an oral diet would lead to the client receiving up to double the daily recommended nutritional intake.

The nurse is implementing orders for a client undergoing a barium enema. Aside from the radiology department, which hospital department should be notified of the procedure? A. The cardiac catheterization department. B. The dietary department. C. The nuclear medicine department. D. The hospital laboratory department.

Explanation Choice B is correct. As part of the preparations for a barium enema, the client needs to be on NPO for 8 - 10 hours. The dietary department needs to be informed about withholding meals within the NPO period. Choice A is incorrect. The procedure is performed in the radiology department, not the cardiac catheterization department. Therefore the cardiac catheterization department does not need to be informed. Choice C is incorrect. The procedure does not contain any nuclear material; therefore, the nuclear medicine department does not need to be informed. Choice D is incorrect. The laboratory should not be informed as it does not involve the laboratory. Last Updated - 15, Feb 2022

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute B. High-pitched bowel sounds at a rate of 4 per minute C. Bowel sounds greater than 60 per minute D. Low-pitched bowel sounds at a rate of 30 per minute

Explanation Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult. Choice A is incorrect. Bowel sounds of 14 per minute are considered normal. Choice C is incorrect. Although bowel sounds more significant than 30 per minute are considered hyperactive, it is not as immediate a concern as choice B. Choice D is incorrect. Bowel sounds usually are high-pitched. However, the rate of bowel sounds here is more normal than choice B. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 15, Feb 2022

A 25-year-old female reports intermittent abdominal pain, bloating, and flatulence that has lasted for several months. Which of the following would the nurse tell the patient to avoid? A. Fiber B. Broccoli C. Yogurt D. Simple carbohydrates

Explanation Choice B is correct. Broccoli forms gas in the stomach and should be avoided for this patient. Choice A is incorrect. High fiber foods help assemble waste in the intestine by adding bulk to stool. Choice C is incorrect. Yogurt can help eliminate toxins and replace lousy gut bacteria with healthy bacteria. Choice D is incorrect. Complex carbohydrates are more likely to cause abdominal discomfort than simple carbohydrates. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Imbalanced Nutrition as the Etiology Last Updated - 05, Feb 2022

The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A. Homan's sign B. Cullen's sign C. Hyperactive bowel sounds D. Kernig's sign

Explanation Choice B is correct. Cullen's sign refers to the bluish periumbilical discoloration/ecchymosis that is common in acute pancreatitis. The discoloration occurs due to blood-stained exudates seeping from the pancreas. Choice A is incorrect. A positive Homan's sign (pain in the calf with foot dorsiflexion) would indicate the presence of a DVT, not pancreatitis. Choice C is incorrect. A patient with acute pancreatitis would present with hypoactive (decreased) bowel sounds, not hyperactive. Choice D is incorrect. A positive Kernig's sign indicates possible subarachnoid hemorrhage or meningitis. It would not support the patient's acute pancreatitis diagnosis. NCSBN Client Need Topic: Adult health - Endocrine, Subtopic: techniques of physical assessment, pathophysiology

Which of the following is the final step that is used during the physical assessment of the abdomen? A. Inspection B. Deep palpation C. Percussion D. None of the above

Explanation Choice B is correct. Deep palpation is cautiously done after light palpation when necessary because the client's responses to deep palpation may include their tightening of the abdominal muscles. When this occurs, it could make light palpation less effective, particularly if an area of pain or tenderness has been palpated. A complete health assessment may be conducted starting at the head and proceeding systematically downward (head-to-toe evaluation). However, the procedure can vary according to the age of the individual, the severity of the illness, the preferences of the nurse, the location of the examination, and the agency's priorities and procedures. Choice A is incorrect. Inspection is typically the first step of an assessment. Choice C is incorrect. Percussion of the abdomen should be done before any palpation, especially deep palpation. Choice D is incorrect. Since choices A and C are incorrect, choice D is also wrong. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: The Health Assessment - Abdomen Last Updated - 19, Nov 2021

Your 65-year-old male client is status-post fecal diversion ostomy two days ago. The nursing staff has been caring for the client, the ostomy, the irrigation, and the application of the collection pouch. You have planned the education and training for this client to begin their ostomy self-care, however, when you tell the client that you will be teaching him how to do this carefully so he will be able to do it after discharge, the client states, "I do not want to even look at it. I will have my wife take care of it when I get home." Which nursing diagnosis is the most appropriate and the highest priority for this client? A. At risk for disturbed body image related to an ostomy B. Disturbed body image related to a fecal diversion ostomy C. A knowledge deficit related to the importance of self care D. A knowledge deficit related to colostomy self care Submit Answer

Explanation Choice B is correct. Disturbed body image related to a fecal diversion ostomy is the most appropriate and the highest priority for this client at this time because the client's subjective data in terms of their statement that "I do not want to even look at it" is an indication that the client actually has a disturbed body image. Choice A is incorrect. At risk for disturbed body image related to an ostomy is not the most appropriate and the highest priority for this client at this time because the client's subjective data in terms of their statement that "I do not want to even look at it" indicates that there should be an actual nursing diagnosis and no longer an "at-risk" nursing diagnosis. Choice C is incorrect. A knowledge deficit related to the importance of self-care is an appropriate nursing diagnosis for this client; however, it is not the most appropriate and the highest priority for this client at this time because the more basic need has to be addressed first before this education can begin. Choice D is incorrect. A knowledge deficit related to colostomy self-care is an appropriate nursing diagnosis for this client; however, it is not the most appropriate and the highest priority for this client at this time because a more basic need has to be addressed first before this education can begin. Last Updated - 11, Feb 2022

The patient is admitted to the ICU following a motor vehicle accident in which he sustained multiple fractures. He is scheduled to go to surgery for repair of his fractured femur. The physician has ordered famotidine 20 mg IV as one of the pre-operative medications. The nurse knows that this medication will: A. Decrease pain B. Help prevent ulcers C. Promote post-op healing D. Treat nausea

Explanation Choice B is correct. Famotidine is a histamine antagonist often referred to as an H2-blocker. This class of drugs treats and prevents duodenal and gastric ulcers caused by increased acid production in the stomach. In the pre-operative setting, it can also be used to reduce the risk of aspiration pneumonitis that can be caused by reflux from increased stomach acid. As the histamine antagonist name suggests, famotidine blocks the action of histamine in the cells of the stomach, which reduces the secretion of acid into the stomach. Choices A, C, and D are incorrect. This class of medications does not decrease pain, treat nausea, or promote post-operative healing. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies Sub-Topic: Expected Actions/Outcomes, Gastrointestinal/Nutrition Last Updated - 20, Jan 2022

The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN) for three days. After reviewing the client's laboratory data, the nurse should take which action? See the image below. A. Reduce the infusion rate of the TPN. B. Obtain a prescription for sliding scale insulin. C. Assess for signs and symptoms of hyperglycemia. D. Pause the infusion for two hours and then reassess blood glucose. Submit Answer

Explanation Choice B is correct. Hyperglycemia is common with both pancreatitis and the infusion of TPN. The client's blood glucose shows an elevation pattern, but it is not hyperglycemic. The nurse needs to act to maintain normoglycemia. The blood glucose target for a client receiving TPN is less than 180 mg/dL. It is the trend over the course of the three days that causes the nurse to be concerned about this problem. A sliding scale of insulin combined with insulin added to the TPN Choices A, C, and D are incorrect. Reducing the rate of the TPN could be detrimental to the client's nutritional status. TPN is prescribed at a fixed rate that is detailed on the bag. The only time the nurse should reduce the rate of the TPN is when the TPN is prescribed to be discontinued. In this case, the nurse should taper in a stepwise fashion. Assessing for signs and symptoms of hyperglycemia is not necessary because the client does not meet the clinical threshold of hyperglycemia (250 mg/dL or greater). Pausing the infusion for two hours should not happen because this could allow the client to develop hypoglycemia.

The nurse is caring for a client receiving lactulose. Which of the following finding would indicate a therapeutic response? A. Increased liver enzymes B. Increased level of consciousness C. Decreased urinary calcium D. Increased gastric pH

Explanation Choice B is correct. Lactulose is indicated for clients with hyperammonemia secondary to cirrhosis of the liver. Increased ammonia levels cause a patient to develop altered mental status (hepatic encephalopathy). A client receiving this medication will have increased bowel movements as that is the primary way of excreting the excess ammonia. Choices A, C, and D are incorrect. Lactulose is intended to decrease ammonia levels - not liver enzymes. Urinary calcium is not impacted by lactulose, and medications such as hydrochlorothiazide will lower urinary calcium. Gastric pH is not increased by lactulose. Additional Info Hepatic encephalopathy can cause a patient to make irrational decisions, as excessive ammonia is a neurotoxin. The high levels of ammonia can be treated by administering lactulose and correcting hypokalemia (this contributes to the accumulation of ammonia).

Which of the following conditions would be a possible cause of hyperactive bowel sounds? A. Paralytic ileus B. Gastroenteritis C. Late bowel obstruction D. Peritonitis

Explanation Choice B is correct. Of the options listed, gastroenteritis would be the only possible cause of hyperactive bowel sounds. Choice A is incorrect. Paralytic ileus would result in hypoactive (diminished) bowel sounds, not hyperactive. Choice C is incorrect. Late bowel obstruction would be associated with hypoactive or absent bowel sounds. Choice D is incorrect. Peritonitis would result in diminished bowel sounds due to inflammation. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: potential for alterations in body systems, system-specific assessments Last Updated - 20, Dec 2021

The nurse is assessing a client with pancreatitis. Which of the following type of pain would be expected? A. Burning, aching pain in the left lower quadrant radiating to the hip. B. Severe pain in the mid-epigastric area radiating to the back. C. Burning, aching pain in the epigastric area radiating to the umbilicus. D. Severe pain in the left lower quadrant radiating to the groin.

Explanation Choice B is correct. Pain in pancreatitis is described as severe and maximal in intensity. It begins mid-epigastrium and radiates to the back; sometimes, it radiates to the chest, flanks, and lower abdomen. Choice A is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice C is incorrect. Pain in pancreatitis is described as severe pain, not burning or aching pain. Choice D is incorrect. Pain in pancreatitis starts in the mid-epigastric area and radiates to the back, chest, and lower abdomen. It does not radiate to the groin. Acute pancreatitis may cause hypovolemic shock, and the client should be resuscitated with isotonic intravenous fluids once a diagnosis is made to prevent this complication. Pancreatitis may be triggered by cholelithiasis or alcoholism. This disorder commonly causes a client to experience intense epigastric pain, nausea/vomiting, and sometimes jaundice.

The nurse is caring for a client with a paralytic ileus following an appendectomy. Which intervention would be appropriate for the nurse to take? A. Assess the client for hyperkalemia B. Prepare for the insertion of a nasogastric tube C. Assess the surgical wound for approximation D. Instruct the client to chew their food more slowly

Explanation Choice B is correct. Paralytic ileus is a possible complication from the anesthesia used during abdominal surgery. An NG tube is placed to decompress the bowel until surgical interventions are implemented or until spontaneous bowel function returns. Choices A, C, and D are incorrect. Assessing the client for hyperkalemia is not a cause of paralytic ileus. Normal to high potassium levels maintain or increase bowel motility. Hypokalemia contributes to the development of an ileus because it slows gastrointestinal motility. The surgical wound has no relevance to the development of a paralytic ileus which is a gastrointestinal complication. Having the client chew their food more slowly would not assist in mitigating a current ileus. If paralytic ileus is suspected, the client is placed on a nothing-by-mouth (NPO) status. Additional Info A paralytic ileus is a complication that may occur after surgery. It manifests as abdominal distention, hiccups, persistent nausea and vomiting, absence or hypoactive bowel sounds, and obstipation. Prokinetic agents such as metoclopramide may be utilized in its treatment. If medications are ineffective, a nasogastric tube (NGT) may be placed for gastric decompression. A key preventative measure for a paralytic ileus would be promptly recognizing hypokalemia. Hypokalemia slows gastrointestinal motility and may contribute to this complication. Hypokalemia is a common electrolyte disturbance following surgery; thus, this complication is common after surgery. Last Updated - 11, Dec 2022

Which of the following conditions would not be an indication for parenteral nutrition? A. Chronic, severe diarrhea B. Dumping syndrome C. Gastrointestinal obstruction D. Enterocutaneous fistula

Explanation Choice B is correct. Parenteral nutrition delivers nutrients to the body via the bloodstream rather than the GI tract and may be indicated in conditions where absorption is impaired. Dumping syndrome is not an indicator of parenteral nutrition because it is not an absorption issue. Dumping syndrome is a potential complication after surgical removal of a large part of the stomach and pyloric sphincter. The stomach has poor control over the number of gastric contents released into the small intestine, so large amounts enter, pulling fluid into the bowels. Treatment focuses on dietary modifications: small meals of dry foods with low carbohydrates, low sugar, and moderate protein and fat. Patients should also allow for rest periods following each meal. Symptoms generally resolve within several months to a year following the surgery. Choice A is incorrect. A patient with chronic, severe diarrhea or vomiting may require parenteral nutrition due to the body's inability to keep food in the GI tract long enough to absorb nutrients. Choice C is incorrect. A patient with obstruction of the GI tract would be at risk of decreased absorption and may require parenteral nutrition, depending on the severity of the blockage. Choice D is incorrect. An enterocutaneous fistula (ECF) describes an abnormal tract between the stomach or intestines and the skin. The presence of an ECF allows for the leaking of the gastrointestinal contents, preventing normal absorption of oral intake. Temporary parenteral nutrition may be needed to provide the patient with adequate nutrients and electrolytes until the fistula is corrected. NCSBN Client Need Topic: GI/Nutrition, Subtopic: Nutrition and oral hydration, illness management Last Updated - 27, Dec 2021

Where would the nurse expect to assess tympany when performing percussion on a patient with ascites? A. Sides of abdomen B. Over the top of the abdomen C. Below the umbilicus D. Over the umbilicus

Explanation Choice B is correct. Patients with ascites present with tightly stretched skin over a rounded, distended abdomen due to accumulation of fluid in the peritoneal cavity typically related to liver disease, portal hypertension, tuberculosis, or nephritic syndrome. Upon percussion of the abdomen, the nurse would expect to note tympany over the top of the abdomen where the intestines float, and dullness over the sides where fluid settles (fluid shifts when the patient is turned to the side). Choices A, C, and D are incorrect. Dullness is percussed over the sides of the abdomen where fluid settles (fluid shifts when the patient is turned to the side) Learning objective: Abdominal percussion can help identify ascites. A tympanic note over the top of the abdomen and dullness over the sides is a characteristic finding. When there is a tense ascites, a fluid thrill may also be elicited.

The nurse is helping a client prepare for his peritoneoscopy tomorrow. All of the following statements from the nurse are accurate regarding the procedure, except: A. "The doctor will inflate your abdomen using carbon dioxide gas." B. "We will be injecting a dye into your vein in order for us to see the organs better." C. "You need to avoid eating or drinking after midnight to prepare for the procedure." D. "Expect to have some discomfort on your shoulders after the procedure; this is because of the air that's left inside your abdomen."

Explanation Choice B is correct. This is an incorrect statement from the nurse, therefore the correct answer to the question. The procedure does not require a contrast medium. The nurse should not say this to the patient. Choice A is incorrect. This is a correct statement from the nurse. The patient's peritoneum is separated from the abdominal wall by pumping 3-4 liters of carbon dioxide. Choice C is incorrect. This is a correct statement from the nurse. The client will be put on NPO after midnight on the night before his procedure. Choice D is incorrect. This is a correct statement from the nurse. Because of pneumoperitoneum, the client should expect discomfort in his shoulder after the procedure up to 24 hours. Last Updated - 11, Feb 2022

Which of the following clients is at greatest risk for developing malnutrition? A. A 72-year-old woman in a nursing home B. An 81-year-old widow who lives alone C. A 65-year-old with poor dentition who is married D. A 79-year-old widower who receives food from 'Meals on Wheels'

Explanation Choice B is correct. This patient has two risk factors, which make her a higher risk for developing malnutrition. Malnutrition refers to deficiencies, excesses, or imbalances in a person's intake of energy and nutrients. The term malnutrition addresses three broad groups of conditions: Undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age), and underweight (low weight-for-age) Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess Overweight, obesity, and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and some cancers) Women, infants, children, and adolescents are at particular risk of malnutrition. Optimizing nutrition early in life—including the 1000 days from conception to a child's second birthday—ensures the best possible start in life, with long-term benefits. Poverty amplifies the risk of, and threats from, malnutrition. Poor people are more likely to be affected by different forms of malnutrition. Also, hunger increases health care costs, reduces productivity, and slows economic growth, which can perpetuate a cycle of poverty and ill-health. Choices A, C, and D are incorrect. While each of these clients may experience poor nutrition and develop malnutrition, if untreated, the patient in answer choice B has two risk factors which make her the highest risk for developing malnutrition. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential Last Updated - 23, Jan 2022

A client who has a gastrostomy tube in place is being discharged. Enteral feedings will be continued at home. While educating the client and family, which statement made by a family member indicates the need for further teaching? A. "If he gets diarrhea for 2-3 days, I will call the doctor or nurse." B. "I should expect a weight gain of about 1 lb/day now that he is on continuous feedings." C. "When feeding, I should keep the head of his bed elevated or sit him in the chair." D. "Prepared or open formula should be used within 24 hours and unused portions should be stored in the fridge."

Explanation Choice B is correct. This statement needs further teaching. A weight gain of more than 1lb/ day is not an expected finding for a client on tube feedings. Such excessive weight gain indicates fluid retention. A consistent weight gain of more than 0.5 lb/day over several days should be promptly reported to the health care provider so that the client may be evaluated for excess fluid volume. Choices A, C, and D are incorrect. These statements reflect accurate understanding and do not need further teaching. Enteral feedings are best administered with the client's head elevated to prevent reflux and aspiration pneumonia. The unused formula should be placed in the refrigerator to avoid bacterial proliferation. If the formula is contaminated, it may lead to gastroenteritis and even sepsis. Diarrhea is a common complication of tube feedings. Hypertonic formulas draw fluid into the bowel and precipitate osmotic diarrhea. Other causes may be bacterial contamination, fecal impaction, medications, and low albumin. Diarrhea can lead to dehydration and should be promptly reported. Learning Objective Understand the common side effects and complications of tube feedings. The nurse should monitor the clients for excessive weight gain, electrolyte imbalances, and diarrhea. Excessive weight gain on tube feedings indicates fluid retention and must be promptly addressed. Last Updated - 20, Jan 2022

What percussion sound is heard over most of the abdomen? Correct A. Hyperresonance B. Tympany C. Resonance D. Dullness

Explanation Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. Choice A is incorrect. Hyperresonance is the sound heard by tapping on the surface of the chest. It is an exaggerated chest resonance heard in various abnormal pulmonary conditions. Choice C is incorrect. Resonance is a low-pitched, hollow sound, is usually heard over healthy lung tissue. Choice D is incorrect. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Physiological Adaptation; Percussion Sounds Last Updated - 10, Feb 2022

The nurse is assessing a client with ulcerative colitis. Which of the following would be an expected finding? A. Projectile vomiting B. Frequent bloody stools C. Absent bowel sounds D. Periumbilical bruising

Explanation Choice B is correct. Ulcerative colitis has clinical features such as frequent bloody stools, iron deficiency anemia, colicky abdominal pain, fever, fatigue, and weight loss. Choices A, C, and D are incorrect. Ulcerative colitis does not cause a client to have projectile vomiting. This would be a feature most associated with pyloric stenosis. The bowel sounds associated with ulcerative colitis are high-pitched. Periumbilical bruising is a problematic feature of necrotizing pancreatitis. NCLEX Category: Physiological Adaptation Activity Statement: Alterations in Body Systems Question type: Knowledge/comprehension Additional Info Ulcerative colitis is an inflammatory bowel disorder that may cause an individual to have classic colicky abdominal pain that may produce multiple bloody stools. This, in turn, may cause an individual to become dehydrated and anemic. Nursing care is aimed at symptom management and providing prescribed medications such as steroids during exacerbations and immunomodulators to reduce flares.

A nurse receives a client who just returned from an endoscopy, during which the client was sedated. Before resuming the client's diet, which of the following should the nurse prioritize? A. Assess the client's oxygenation level B. Assess for the return of the client's gag reflex C. Position the client on his side D. Have the client take sips of water

Explanation Choice B is correct. Undergoing an endoscopy generally requires intravenous sedation, therefore impairing the client's gag reflex. Here, since the question asks what the nurse should prioritize before resuming the client's diet, the priority is to closely monitor the client until the effects of the sedation have resolved and the client's gag reflex has returned. Attempting to provide the client with oral intake before ensuring the return of the gag reflex may result in airway obstruction and/or aspiration. Choice A is incorrect. Monitoring the client's oxygenation levels is essential following an endoscopic procedure, but in relation to resuming the client's diet, this is not the nurse's priority. Choice C is incorrect. Positioning the client on their side is not a required intervention following an endoscopy. Choice D is incorrect. In order to assess the return of the client's gag reflex following the use of sedation, offering the client sips of water is not the proper assessment method, as this method places the client at risk of aspiration. Learning Objective In a post-endoscopy client, recognize the need to prioritize assessing the return of the client's gag reflex prior to resuming the client's diet. Additional Info Maintain NPO status until the anesthesia has worn off and the gag reflex has returned. Provide the client with an emesis basin, and instruct the client to spit out saliva rather than swallow it. Following the return of the client's gag reflex, the client may resume their normal diet, beginning with sips of water or ice chips. If the client resumes oral intake too soon, airway obstruction and/or aspiration may occur. Aspiration can cause acute pneumonia.

A nurse is assigned to care for a client with liver dysfunction and ascites and is ordered to measure the client's abdominal girth daily. To ensure accuracy, the nurse should utilize which landmark? A. Xiphoid process B. Umbilicus C. Iliac crest D. Symphysis pubis

Explanation Choice B is correct. With ascites, free fluid accumulates primarily in the abdominal cavity. As liver dysfunction worsens, ascites typically increase, increasing the abdominal girth. When measuring abdominal girth, standard practice dictates using the umbilicus as the landmark to be utilized when measuring a client's abdominal girth. The technique involves encircling the abdomen with a measuring tape at the level of the umbilicus. Using this method, you ensure the client's future measurements are accurate and comparable to prior measurements, even if performed by other clinicians. Choice A is incorrect. The xiphoid process, located at the inferior portion of the sternum, would not provide an accurate measurement of abdominal girth. Choice C is incorrect. The iliac crest, located at the superior border of the ilium extending from the anterior superior iliac spine to the posterior superior iliac spine, would not accurately measure abdominal girth. Choice D is incorrect. The symphysis pubis, a joint located between the left and right pelvic bones, would not provide an accurate measurement of abdominal girth if used as a landmark. Learning Objective When caring for a client with liver dysfunction and ascites, recognize the need to utilize the umbilicus as the landmark when assessing daily abdominal girth measurements. Additional Info The primary sign of ascites is an increase in abdominal girth and weight gain. Ascites is free fluid in the abdominal cavity, usually caused by portal hypertension or other hepatic or nonhepatic conditions. Moderate amounts of fluid can increase abdominal girth and cause weight gain, and massive amounts can cause abdominal distention, pressure, and dyspnea. Signs may be absent if fluid accumulation is < 1500 mL. Unless the diagnosis is obvious, confirm the presence of ascites using ultrasonography or CT. If ascites is a new diagnosis, the cause is unknown, or spontaneous bacterial peritonitis is suspected, the health care provider (HCP) will often order paracentesis and test ascitic fluid.

You are caring for a client who is 5 foot 6 inches tall and has a BMI of 28. This client is now on a regular diet. You would most likely recommend: A. Continuing their diet as it is B. Weight reduction with diet and exercise C. A high caloric diet to gain weight D. Nothing at all, this client is normal Submit Answer

Explanation Choice B is correct. You would most likely recommend weight reduction with diet and exercise for this client who is 5 foot 6 inches tall and has a body mass index (BMI) of 28 because this client is overweight. The ranges for BMI are as follows: Underweight: Under 18.5 Normal: From 18.5 to 24.9 Overweight: From 25 to 29.5 Obesity: From 30 to 39.9 Extreme obesity: Over 40 Choice A is incorrect. You would not advise the client to continue with their current diet and nutritional intake because a body mass index (BMI) of 28 indicates the need for education about dietary intake. Choice C is incorrect. You would not advise the client to begin a high caloric diet to gain weight because a body mass index (BMI) of 28 indicates the need for education about dietary intake. Choice D is incorrect. A body mass index (BMI) of 28 indicates the need for education about dietary intake and exercise. Last Updated - 17, Dec 2021

You are caring for a client who is in the burn unit with severe burns. Since this is your first client contact with this person, you introduce yourself and tell the client that they will be taken care of by you for this shift. The client greets you and states, "Why am I getting this stuff that is hanging up here?" as they are pointing to the ordered total parenteral infusion. You should: A. Respond to the client stating, "I don't think you should be getting this. I am going to call your doctor." B. Respond to the client stating, "This is total parenteral nutrition and you are getting it because your nutritional status is impaired as the result of your burns". C. Respond to the client stating, "This is total parenteral nutrition and you are getting it because your nutritional status is impaired because you aren't eating enough." D. Respond to the client stating, "I don't think you should be getting this. I am going to turn it off now."

Explanation Choice B is correct. You would respond to the client stating, "This is total parenteral nutrition, and you are getting it because your nutritional status is impaired as the result of your burns." Many clients with severe burn injuries get parenteral nutrition to meet the nutritional demands of burn injuries like those associated with a negative nitrogen balance, which indicates a deficiency of protein. Choice A is incorrect. You would not respond to the client stating, "I don't think you should be getting this. I am going to call your doctor." You should know why the client is getting this nutritional treatment, and you should be able to explain the purpose of this dietary treatment to the questioning client. Choice C is incorrect. You would not respond to the client stating, "This is total parenteral nutrition, and you are getting it because your nutritional status is impaired because you aren't eating enough." You should know that the reason for the parenteral nutrition is not related to the client's oral input of food and fluids but, instead, another reason. Choice D is incorrect. You would not respond to the client stating, "I don't think you should be getting this. I am going to turn it off now." You should know the reason for the parenteral nutrition and you should be able to explain the purpose of this nutritional treatment to the questioning client. You would also not discontinue the parenteral nutrition without a doctor's order. Last Updated - 03, Jun 2021

The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include? A. "You should take aspirin if you have mild aches or pains." B. "You will need to consume liquids one hour after each meal." C. "It will be important to reduce the stress in your life." D. "Take your prescribed omeprazole with food."

Explanation Choice C is correct. A client with peptic ulcer disease will need to reduce the amount of stress in their life to mitigate some of the symptoms. Ulcers are caused by excessive use of non-steroidal anti-inflammatory drugs, alcoholism, and stress. Choices A, B, and D are incorrect. Aspirin and NSAIDs should not be taken for a client with peptic ulcer disease as they can hasten the disease process and cause bleeding. Consuming liquids one hour after meals is appropriate instruction for a client with dumping syndrome - not peptic ulcer disease. Omeprazole is a proton pump inhibitor and should be given without any other medications or food. Additional Info Peptic ulcer disease may be caused by alcoholism, H. pylori infections, gastritis, NSAIDs, and corticosteroids. Complications include hemorrhage, perforation, and pyloric obstruction. Last Updated - 10, Feb 2022

The nurse is preparing a client for a paracentesis. Which nursing actions should not be included in the nursing care plan? A. Obtain the client's vital signs and weight before and after the procedure. B. Have the client void before the procedure. C. Apply a large pressure dressing after the procedure. D. Maintain the client on bed rest.

Explanation Choice C is correct. A dressing is applied after the procedure, but a large pressure dressing is not required. Choice A is incorrect. The nurse needs to take pre-procedure vital signs, including weight, to establish a baseline. The pressure is taken before and after the procedure to indicate the effectiveness of the system in fluid removal. Choice B is incorrect. The client is made to void before the procedure to make sure that the bladder is not full and prevents it from being punctured. Choice D is incorrect. The client is maintained on bed rest after the procedure to assess the client for any complications. Last Updated - 14, Sep 2021

The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention in the client's plan of care following the procedure? A. Administer analgesics to control pain. B. Monitor for signs of infection. C. Monitor for signs of hypovolemic shock. D. Ensure that the ascetic fluid is sent to the lab for analysis.

Explanation Choice C is correct. A major complication of paracentesis is hypovolemic shock secondary to fluid drainage from the peritoneum; resulting in a fluid shift from intravascular to interstitial space and the sudden change in intraabdominal pressure on the vessels. The nurse should observe for pallor, tachycardia, hypotension, oliguria, and dyspnea. Choice A is incorrect. Abdominal pain after paracentesis can be treated with NSAIDs; however, it is not a significant complication of the procedure. Choice B is incorrect. Infection may occur after a paracentesis; however, signs of infection will not be apparent until after 24 hours. Choice D is incorrect. After the procedure, the primary concern of the nurse is to assess and prevent complications in the client. The nurse may ensure that the aspirated fluid is sent to the lab for analysis, but it should not take priority over the patient. Last Updated - 15, Feb 2022

The nurse is educating a client about their newly prescribed soft diet. It would be appropriate for the nurse to suggest which food item? A. Chunky peanut butter B. Raw carrot sticks C. Applesauce D. Beef jerky

Explanation Choice C is correct. A soft diet is commonly used for individuals with problems with swallowing, chewing, or trauma to the jaw. Applesauce has a smooth texture acceptable for a client prescribed a soft diet. Choices A, B, and D are incorrect. Nuts, seeds, raw vegetables, and fruits should be avoided in a soft diet. These food items do not qualify as soft foods. Additional Info A soft diet may be used for mouth or jaw trauma. Further, it may be used for clients who have dysphagia. Foods permitted in a soft diet include applesauce, canned fruit, soft fruit such as bananas, steamed vegetables, and cooked pasta. Last Updated - 04, Nov 2022

The nurse is assessing a client who is newly diagnosed with irritable bowel syndrome (IBS). Which of the following findings is consistent with this diagnosis? A. Unexplained weight loss B. Epigastric pain and nausea C. Alternating constipation and diarrhea D. Low-grade fever and fatigue

Explanation Choice C is correct. Alternating constipation and diarrhea are the hallmark manifestations associated with irritable bowel syndrome (IBS). Choices A, B, and D are incorrect. Unexplained weight loss is a finding associated with multiple diseases, including colon cancer. This is not a finding relevant to IBS. Epigastric pain and nausea may be a symptom associated with pancreatitis. Finally, IBS is not an infectious process, and a fever is not an accurate clinical finding. Additional Info IBS is a disorder that manifests with alternating periods of constipation and diarrhea. While some clients may have one symptom over another, the disorder is associated with pain with defection (or after defecation), excessive flatulence, and abdominal bloating. The symptoms may relapse and remit and can be triggered by stress or food. Treatment is symptomatic with an emphasis on preventing the occurrence of triggers. Last Updated - 23, Dec 2021

Select the complication of parenteral nutrition that is accurately paired with its etiology. A. Dehydration: The hyperosmolar nature of the nutritional solution B. Dehydration: The lack of adequate water with feedings C. Air embolus: A failure to properly clamp the IV tubing D. Pneumothorax: A failure to properly secure the IV tubing Submit Answer

Explanation Choice C is correct. An air embolus is a complication of parenteral nutrition, which can occur as the result of several causes, including a failure to clamp the IV tubing properly, the inadvertent disconnection of the intravenous tubing, and the accidental disconnection of the injection port. Choice A is incorrect. Dehydration occurs as a complication of enteral nutrition rather than total parenteral nutrition. The hyperosmolar nature of the enteral nutritional solution can lead to dehydration. Choice B is incorrect. Dehydration occurs as a complication of enteral nutrition rather than total parenteral nutrition. The lack of adequate water with the feedings and between these enteral nutritional feedings can lead to dehydration. Choice D is incorrect. Although pneumothorax is a complication of parenteral nutrition, pneumothorax does not result from a failure to secure the IV tubing properly; this complication can occur as the result of an inadvertent and accidental puncture of the lung's pleural cavity during insertion. Last Updated - 23, Jan 2022

Primary nutrients that are essential for optimal body function include: A. Iron, zinc, and calcium B. Folate, vitamin B12, and iron C. Carbohydrates, proteins, and fats D. Vitamins A, D, E, and K

Explanation Choice C is correct. Carbohydrates, proteins, and fats provide the energy that is necessary for cellular function. Choice A is incorrect. Iron, zinc, and calcium are three essential minerals. Choice B is incorrect. Folate, vitamin B12, and iron are necessary for oxygenation as well as optimal hemoglobin and hematocrit counts. Choice D is incorrect. Vitamins A, D, E, and K are fat-soluble. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Primary Nutrients Last Updated - 08, Nov 2021

A 42-year-old female client reports colicky abdominal pain that worsens after eating a high-fat meal. The nurse anticipates that this client has which diagnosis? A. Gastric ulcer B. Appendicitis C. Cholecystitis D. Liver cirrhosis

Explanation Choice C is correct. Cholecystitis occurs most commonly in women older than age 40 who haven't gone through menopause. Its manifestations include episodic, colicky pain in the epigastric area that radiates to the back and shoulder. Pain in cholecystitis resembles indigestion or chest pain after eating fatty or fried foods. Choice A, B, and D are incorrect. A gastric ulcer is an ulceration of the mucosal lining that extends to the submucosal layer of the stomach. Its manifestations include a gnawing, sharp pain in the left mid-epigastric region 30-60 minutes after a meal. Appendicitis is the inflammation of the appendix. It is manifested by pain in the periumbilical area that descends to the right lower quadrant. Cirrhosis is a chronic hepatic disease characterized by diffuse destruction of hepatic cells, replaced by fibrous cells. The symptoms presented by the patient do not indicate liver cirrhosis. Additional Info Risk factors for cholecystitis include: • Women of all ages (risk of calculi increases with aging) • American Indian, Mexican American, or Caucasian • Obesity • Rapid weight loss or prolonged fasting; low-fat diet • Increased serum cholesterol and lipids • Women on hormone replacement therapy (HRT) Manifestations of cholecystitis include: Constant pain in the right upper abdominal quadrant. It may radiate to the right shoulder or scapula. Nausea, vomiting, and reports of indigestion.

When caring for a client with total parenteral nutrition (TPN), what is the most important action by the nurse? A. Record the number of stools per day B. Maintain strict intake and output records C. Sterile technique for dressing change at IV site D. Monitor for cardiac arrhythmias

Explanation Choice C is correct. Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are an excellent medium for bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site. Choices A, B, and D are incorrect. Although these are appropriate nursing interventions, they are not the essential action of the nurse in this example. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies

The process of absorbing drugs before elimination after they have been excreted into bile and delivered to the intestines is called: A. Hepatic clearance B. Total clearance C. Enterohepatic cycling D. First-pass effect

Explanation Choice C is correct. Drugs and drug metabolites with molecular weights higher than 300 may be excreted via the bile, stored in the gallbladder, delivered to the intestines by the bile duct, and then reabsorbed into the circulation. This process reduces the elimination of drugs and prolongs their half-life and duration of action in the body. Before drugs can be clinically useful, they must be absorbed. Absorption is the process of a drug moving from its site of delivery into the bloodstream. The chemical composition of a drug, as well as the environment into which a drug is placed, work together to determine the rate and extent of drug absorption. Absorption can be accomplished by administering the drug in a variety of different ways (orally, rectally, intramuscularly, subcutaneously, inhalation, topically, etc.). If a drug is administered intravenously, the need for absorption is bypassed entirely. For drug absorption to be most efficient, the properties of the drug itself and the pH of the environment where the drug is located must be considered. Most drugs are either weak acids or weak bases. Drugs that are weak acids will pick up a proton when placed in an acidic environment and will be un-ionized. Other factors that also impact drug absorption include the following: Physiologically, a drug's absorption is enhanced if there is a large surface area available for absorption (villi/microvilli of the intestinal tract) and if there is a large blood supply for the drug to move down its concentration gradient. The presence of food/other medications in the stomach may impact drug absorption - sometimes enhancing absorption and other times, forming insoluble complexes that are not absorbed (it depends on the specific drug). Some drugs are inactivated before they can be absorbed by enzymes, acidity, bacteria, etc. Choice A is incorrect. Hepatic clearance is the amount of drug eliminated by the liver. Choice B is incorrect. Total clearance is the sum of all types of removal, including renal, hepatic, and respiratory. Choice D is incorrect. The first-pass effect is the amount of drug absorbed from the GI tract and then metabolized by the liver; thus, reducing the amount of medicine, making it into the circulation. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological Therapies, What Happens After a Drug Has Been Administered

The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected? A. Stools that contain blood and mucus B. Pain with urination C. Episodic upper abdominal pain D. Hypoactive bowel sounds

Explanation Choice C is correct. Episodic abdominal pain originating in the right upper quadrant or epigastric area is commonly associated with cholecystitis. The pain may be induced by a meal high in fat. Choices A, B, and D are incorrect. Stools containing blood and mucous would be a clinical finding in a patient with ulcerative colitis. Pain with urination (dysuria) would be a manifestation associated with sexually transmitted infections or cystitis. Hypoactive bowel sound is not an expected finding with acute cholecystitis. Additional Info Acute cholecystitis has symptoms such as nausea, vomiting, and right upper quadrant abdominal pain that may radiate to the shoulder blades. Clients often have an intensification of pain when the gallbladder is palpated upon inspiration (Murphy's sign).

The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action prior to the client's exam? A. Remove any medicated patches before the exam B. Instruct the client to empty their bladder right before the test C. Educate the client that they may experience a flushing sensation during the exam D. Assess the client for an implantable pacemaker Submit Answer

Explanation Choice C is correct. Flushing of the face is a response to the intravenous administration of contrast dye commonly seen in clients. Often, clients experience a warm sensation throughout the body once the intravenous contrast dye begins infusing. Usually, if the client does experience this warm sensation, clients will typically report the sensation occurring initially in the face and neck region. Shortly after, clients will often state they feel the warmth in their pelvic area. Choices A, B, and D are incorrect. Removing any medicated patches prior to the exam is an action to be done prior to a magnetic resonance imaging (MRI) test. If they are not removed, the aluminum could cause the client to sustain a burn. The client does not need to empty their bladder before this imaging test. Assessing the client for an implantable pacemaker is an action reserved for an MRI because this is a contraindication to that exam. Additional Info Last Updated - 09, Feb 2023

The patient with appendicitis is experiencing discomfort before her appendectomy. The nurse should avoid which of the following non-pharmaceutical therapies to relieve this discomfort? A. Applying ice packs to the abdomen B. Practicing breathing exercises with the patient C. Using a heating pad D. Encouraging rest

Explanation Choice C is correct. Heat should not be applied to the abdomen of patients experiencing pain from appendicitis. Heat will cause vasodilation and increased blood flow to the appendix which may lead to rupture. A ruptured appendix puts the client at risk for a life-threatening condition known as peritonitis. Choice A is incorrect. Applying ice packs to a patient's abdomen experiencing discomfort related to appendicitis is an appropriate non-pharmaceutical intervention. Choice B is incorrect. Using breathing techniques to work through appendicitis pain is an appropriate non-pharmaceutical intervention. Choice D is incorrect. Encouraging plenty of rest is an excellent way to prevent and manage pain from appendicitis. NCSBN client need Topic: Physiological Adaptation, Basic Care and Comfort

The nurse is caring for a patient who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings would be essential for the nurse to follow-up? A. Incisional pain level of "6" on a 1-10 scale. B. An oral temperature of 99.5 degrees Fahrenheit. C. A heart rate of 112 beats-per-minute (BPM). D. Hypoactive bowel sounds in all four quadrants.

Explanation Choice C is correct. Immediately following abdominal surgery, shock (distributive, hypovolemia) is a concern to the nurse. A heart rate of 112 would indicate tachycardia, which is one of the earliest manifestations of shock, and the nurse needs to assess the client further. Choice B is incorrect. A low-grade temperature is an expected finding following surgery because of the inflammation. Choices A and D are incorrect. Incisional pain and hypoactive bowel sounds are all expected findings in the immediate post-operative period. Last Updated - 18, Jan 2022

A nurse is evaluating an 83-year-old client who has been hospitalized after a fall. He has not had a bowel movement for five days, and a possible fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction? A. Rigid, board-like abdomen B. The client has lost the urge to defecate C. Liquid stool D. Complaints of abdominal pain

Explanation Choice C is correct. In a client with fecal impaction, the client has the urge to defecate but is unable to do so. A liquid stool is usually observed as it is the only thing that will be able to pass around the impacted site. Choices A, B, and D are incorrect. A rigid, board-like abdomen is associated with a perforated bowel, not fecal impaction. Abdominal pain without enlargement is also not associated with fecal impaction. Last Updated - 06, Dec 2021

The nurse is caring for a patient with suspected bowel perforation. Which of the following would be contraindicated for this patient? A. Administering gastrografin for an upper GI x-ray. B. An exploratory laparotomy procedure. C. Administering milk of magnesia following an upper GI study. D. An abdominal CT scan.

Explanation Choice C is correct. Milk of magnesia is a cathartic agent used to promote the excretion of barium sulfate following an upper GI study. Since barium sulfate would not be appropriate for this patient due to bowel perforation, gastrografin would be used instead. Gastrografin may cause diarrhea, which would be exacerbated by giving this patient milk of magnesia. Choice A is incorrect. Water-soluble gastrografin is an osmotic cathartic and is indicated for patients with bowel perforation who require upper GI x-ray studies. Gastrografin is used instead of barium sulfate. Choice B is incorrect. Surgical intervention (i.e. exploratory laparotomy) is commonly used to diagnose and determine the cause of bowel perforation. This procedure would be indicated for this patient unless other issues are present that would prevent the patient from tolerating surgery, such as severe congestive heart failure or multiorgan failure. Choice D is incorrect. Bowel perforation is not a contraindication for a CT scan. CT imaging may be more useful than x-ray in locating bowel perforation due to more sensitive imaging/results. NCSBN Client Need Topic: Gastrointestinal, Subtopic: Diagnostic tests, the potential for complications of diagnostic tests/treatments/procedures, elimination Last Updated - 09, Feb 2022

The nurse is checking the tray of a patient with Celiac disease. Of the following, which meal would be most appropriate for this patient? Correct A. Macaroni and cheese B. A ham sandwich on a wheat roll C. Salmon over roasted beets D. Turkey, potatoes, and garlic bread

Explanation Choice C is correct. Of these options; the best meal is the meal without any gluten-containing substances. Salmon and beets are both gluten-free. Other gluten-free foods include meat, fish, eggs, some dairy, vegetables, corn, fruit, rice, and gluten-free flours. Choice A is incorrect. Macaroni noodles are generally made of wheat unless otherwise stated. Individuals with Celiac disease must avoid all wheat-containing products. This meal would not be the best choice for this patient. Choice B is incorrect. Wheat rolls contain gluten and should, therefore, be avoided in patients with Celiac disease. Choice D is incorrect. Flour-based bread contains gluten and is harmful to individuals with Celiac disease, and therefore, garlic bread should be avoided. NCSBN client need Topic: Physiological Integrity, Nutrition, and Oral Health Last Updated - 03, Feb 2022

The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement? A. Steak and a baked potato B. Brussel sprouts and a whole grain roll C. White rice with chicken D. A ham sandwich with tomato soup

Explanation Choice C is correct. Of these options; the best meal is the meal without any gluten-containing substances. Salmon and beets are both gluten-free. Other gluten-free foods include meat, fish, eggs, some dairy, vegetables, corn, fruit, rice, and gluten-free flours. Choice A is incorrect. Macaroni noodles are generally made of wheat unless otherwise stated. Individuals with Celiac disease must avoid all wheat-containing products. This meal would not be the best choice for this patient. Choice B is incorrect. Wheat rolls contain gluten and should, therefore, be avoided in patients with Celiac disease. Choice D is incorrect. Flour-based bread contains gluten and is harmful to individuals with Celiac disease, and therefore, garlic bread should be avoided. NCSBN client need Topic: Physiological Integrity, Nutrition, and Oral Health Last Updated - 03, Feb 2022

Which of the following interventions is helpful in reducing the effects of GERD? A. Lie down after eating. B. Wear a girdle. C. Elevate the head of the bed on 4-6 inch blocks. D. Increase fluid intake just before bedtime. Submit Answer

Explanation Choice C is correct. Patients should be encouraged to elevate the head of the bed to allow food to move out of the stomach before lying flat. GERD occurs when stomach acid slips into the esophagus. Any position that hinders or slows the movement of food from the stomach should be avoided. Choice A is incorrect. Lying down after eating causes the movement of food out of the stomach to slow, which could aggravate symptoms. Choice B is incorrect. The compression of the stomach reduces its volume and those who wear girdles or waist trainers find that overeating gives them indigestion and heartburn. Choice D is incorrect. When a patient lies in bed shortly after eating or drinking, gravity is not as quickly keeping digestive juices in the stomach. Eating or drinking more than three to four hours before bed reduces the risk of nighttime heartburn. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort Last Updated - 22, Jul 2021

The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure? A. docusate B. loperamide C. polyethylene glycol 3350 D. famotidine

Explanation Choice C is correct. Polyethylene glycol 3350 is a stimulant laxative commonly used before a colonoscopy. This powder is typically dissolved in a sports drink and can be consumed by the client. Efficacy is usually within one hour. Fluid and electrolyte disturbance is unlikely as the powdered solution contains electrolytes. Choices A, B, and D are incorrect. Docusate is a stool softener and is not used to prepare for a colonoscopy. This medication would help prevent constipation. Loperamide is a medication to slow peristalsis and is indicated in the treatment of diarrhea. Famotidine is a histamine blocker and is used to manage peptic ulcer disease. Additional Info When administering this medication, it should be dissolved in water or Gatorade® and may chill in the refrigerator to increase palatability.

The client that is under sodium restrictions is asking the nurse about which seasonings he can use that are low in sodium. The nurse should respond by saying: A. "You can use soy sauce as a dip." B. "You can use ketchup to make it taste better." C. "You can add some rosemary to increase your food's flavor." D. "Steak sauce is a nice way to enhance your food."

Explanation Choice C is correct. Rosemary is a low-sodium seasoning that only has 26 mg of sodium per 100 grams. Choice A is incorrect. Soy sauce is a high-sodium seasoning that has 291.1 mg of sodium per teaspoon. Choice B is incorrect. Ketchup is also a high-sodium seasoning that has 154.2 mg of sodium per tablespoon. Choice D is incorrect. Steak sauce is also a high-sodium seasoning that has 280 mg of sodium per tablespoon. Last Updated - 04, Feb 2022

The nurse is in charge of the care of a client diagnosed with a duodenal ulcer. Which medication will facilitate healing by forming a protective lining over the ulcer? A. Famotidine (Pepcid) B. Ranitidine (Zantac) C. Sucralfate (Carafate) D. Cimetidine (Tagamet)

Explanation Choice C is correct. Sucralfate reacts with gastric acid to form a thick layer of paste that adheres to the surface of the ulcer and will, therefore, prevent further damage and promote healing. Choices A, B, and D are incorrect. These are all histamine H2 antagonists that act by inhibiting gastric acid secretion. Last Updated - 20, Jul 2022

A nurse is caring for a client diagnosed with a duodenal ulcer. Which medication facilitates healing by forming a protective lining over the client's ulcer? A. Famotidine B. Ranitidine C. Sucralfate D. Cimetidine

Explanation Choice C is correct. Sucralfate reacts with gastric acid to form a thick layer of paste that adheres to the ulcer's surface, preventing further damage and promoting healing. Choice A is incorrect. Famotidine is a histamine H2-receptor antagonist that acts by inhibiting gastric acid secretion. Choice B is incorrect. Ranitidine is a histamine H2-receptor antagonist that acts by inhibiting gastric acid secretion. Choice D is incorrect. Cimetidine is a histamine H2-receptor antagonist that acts by inhibiting gastric acid secretion. Learning Objective Recognize sucralfate as the medication which facilitates healing by forming a protective lining over the ulcer. Additional Info Sucralfate is in a class of anti-ulcer medications called protectants.

Your client is receiving an enteral feeding every 4 hours. What is an appropriate expected outcome for this client in terms of the gastrointestinal system? A. The client will be free of any insertion site infection. B. The nurse will measure residual prior to each feeding. C. The client will be free of dumping syndrome. D. The nurse will administer no more than 200 mL for each feeding. Submit Answer

Explanation Choice C is correct. The appropriate expected goal/outcome for this client, in terms of the gastrointestinal system, who is receiving an enteral feeding every 4 hours, is that the client will be free of dumping syndrome. This can further increase the client's nutritional deficits. Simply stated, dumping syndrome is the very rapid and quick movement of foods and fluids through the stomach and then into the small intestine; the feed is then mostly undigested and eliminated through the gastrointestinal tract. Although dumping syndrome is primarily associated with gastric bypass surgery, it can also occur as a result of enteral bolus feedings. Choice A is incorrect. "The client will be free of any insertion site infection" may be an appropriate expected goal/outcome for this client who is receiving an enteral feeding every 4 hours. Still, this outcome is not related to the client's gastrointestinal system. Choice B is incorrect. "The nurse will measure residual before each feeding" is an appropriate nursing intervention, but it is not an expected goal/outcome. Choice D is incorrect. "The nurse will administer no more than 200 mL for each feeding" is not an expected goal/outcome. Moreover, the nurse can administer more than 200 mL for each feeding. The volume of each food is typically from 250 to 400 mL per feeding. Last Updated - 10, Jan 2022

A client with portal-systemic encephalopathy is prescribed lactulose 20 grams orally QID. The medication is available in 3.33 grams per 5 mL oral solution. The nurse is preparing to administer a 30 mL dose of lactulose to this client. When the nurse approaches the client, the client states, "I understand that I cannot take other laxatives with lactulose." Which of the following actions should the nurse perform next? A. Withhold the lactulose B. Give only 3 mL of lactulose instead of 30 mL C. Give 30 mL of lactulose with juice and monitor blood ammonia D. Correct the client's statement by stating additional laxatives may be taken

Explanation Choice C is correct. The client has been prescribed lactulose for portal-systemic encephalopathy (PSE), not for constipation. Lactulose promotes ammonia excretion in the stool by cleansing the bowels and ridding the intestinal tract of the toxins that contribute to encephalopathy. Lactulose increases osmotic pressure to draw fluid into the colon and prevents the absorption of ammonia in the colon. The drug's desired effect is the production of two or three soft stools per day and a decrease in the client's confusion caused by increased ammonia. When observing for a response to lactulose, the client may report intestinal bloating and cramping. Serum ammonia levels may be monitored but do not always correlate with symptoms. Choice A is incorrect. The prescribed dose of lactulose is required for the client's portal-systemic encephalopathy. Withholding this medication could have severe repercussions. Choice B is incorrect. The prescribed dose is 20 grams, which is equivalent to 30 mL. Administering 3 mL instead of 30 mL would be a medication error. Choice D is incorrect. Instructing this client to take additional laxatives while on lactulose would be inappropriate, as the client has already verbalized a correct understanding of the need to avoid other laxatives. Since lactulose is used to promote the excretion of ammonia in stool, the dose must be carefully adjusted, so the client averages two to three loose bowel movements per day. Determining the optimal daily dose of lactulose becomes challenging if other laxatives are used in conjunction. Learning Objective When caring for a portal-systemic encephalopathy client, recognize that lactulose is given to promote ammonia excretion in the stool. Additional Info Due to unfavorable taste, lactulose is often mixed with fruit juice, water, or milk to improve flavor. Hypokalemia and dehydration may result from excessive stools. Remind unlicensed assistive personnel (UAP) to assist the client with skincare (if needed) to prevent breakdown caused by excessive stools.

A patient presents with a body mass index (BMI) of 14. The nurse expects which of the following nursing interventions to be implemented? A. Make sure the patient eats complete meals twice daily. B. Reduce total fat and calorie intake for the client. C. Provide additional high protein and calorie shakes. D. Increase the intake of green leafy vegetables.

Explanation Choice C is correct. The patient is underweight. Body mass index (BMI) is calculated as weight in kilograms divided by height in meters squared. A BMI of 18.5-24.9 is considered healthy. A BMI of less than 18.5 is underweight. A BMI of 25-29 is overweight and a BMI of 30 or higher is obese. To increase BMI, adding healthy food choices is essential. Foods that are rich in nutrients and high in calories include brown rice, granola, raisin bran cereals, bananas, dried apricots, avocados, sweet potatoes, peas, yogurt, milk, and fatty fish such as salmon and tuna, tofu, beans, lean red meat, nuts, and seeds. Choice A is incorrect. An underweight patient should not be limited to two meals daily. Choice B is incorrect. Calorie intake should be increased, not decreased. Choice D is incorrect. An increase in green leafy vegetables is not indicated to increase BMI. Instead, the patient needs an increase in protein and calories. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Last Updated - 18, Nov 2021

The 36-hour postoperative appendectomy patient presents with abdominal guarding and complains of sudden, deep, 10/10 in severity pain. The nurse should implement which action first? A. Obtain an order for PCA B. Administer PRN morphine C. Notify MD of the patient's change in status D. Assess for other signs of pain

Explanation Choice C is correct. The sudden onset of extreme, deep pain likely indicates a complication of the patient's recent surgery. Deep/visceral pain may be related to pressure in the internal viscera due to bleeding or abscess. The nurse has assessed the location, quality, and intensity of the pain and should report the change in status to the physician, so the proper diagnostic tests can be ordered to determine the cause. Choice A is incorrect. A patient-controlled analgesia (PCA) pump may be appropriate to provide more controlled, sustained pain relief for a patient with consistent, moderate to severe pain, but would not be the nurse's first action for a patient who develops sudden, sharp pain. Choice B is incorrect. Opioid analgesics may be necessary for the first 48 hours or longer after surgery to control moderate to severe pain. However, administering pain medication would not be the appropriate first action in addressing this patient's sudden onset of severe pain. Choice D is incorrect. The nurse has already assessed the patient's pain and that the patient is presenting with guarding. The pain must be accepted as what the patient states, so the nurse would not need to wait for other signs/symptoms of illness to develop in order to start implementing interventions. NCSBN Client Need Topic: Critical Care Concepts (medical emergency), Subtopic: Establishing priorities, collaboration with the interdisciplinary team, the potential for complications from surgical procedures Last Updated - 09, Feb 2022

An 86-year-old patient presents with an open wound of the right lower extremity, leucocyte count of 12000/ul, body mass index (BMI) 18.8, and a pre-albumin of 12 mg/dL. Which diet would be most appropriate for this patient? Correct A. Low fiber, low residue B. Total parenteral nutrition (TPN) with iron supplementation C. High calorie, high protein D. Low sodium (heart healthy)

Explanation Choice C is correct. This patient is showing signs in need of increased protein and caloric intake as evidenced by the elevated WBC count (normal WBC range: 4-11), open wound, low albumin level (normal prealbumin range: 15-36mg/dL), and BMI within the normal range, but very close to underweight (normal BMI range: 18.5-24.9). This patient needs increased protein and caloric intake to fight infection and promote wound healing. Choice A is incorrect. A low fiber/residue diet is indicated in GI conditions such as Crohn's disease, IBD, and diverticulitis. No assessment data is suggesting that the patient is experiencing any GI problems. Choice B is incorrect. No assessment data is suggesting that the patient is deficient in iron. TPN is indicated when a patient has an absorption problem or when oral intake is not possible. The patient should be started on an appropriate high-calorie, high protein diet first before any parenteral nutrition is considered. Choice D is incorrect. No assessment data is suggesting that the patient is experiencing any cardiac issues requiring a low sodium/heart-healthy diet. NCSBN Client Need Topic: GI/Nutrition, Subtopic: Nutrition and oral hydration, illness management Last Updated - 09, Dec 2021

The nurse is caring for a client receiving total parenteral nutrition for 2 weeks. Which action by the nurse is the most important? A. Determining weight changes in the client. B. Monitoring laboratory results. C. Maintaining strict asepsis during dressing changes in the IV line. D. Monitoring of blood glucose levels.

Explanation Choice C is correct. Total parenteral nutrition (TPN) has high glucose content making it an ideal medium for bacterial growth. The nurse should perform strict asepsis during dressing changes in the TPN line. Choice A is incorrect. Obtaining the client's weight is essential to assess the client's nutritional status. However, this is not the nurse's priority intervention. Choice B is incorrect. The nurse should monitor laboratory results to monitor changes in electrolytes. However, this is not a priority action. Choice D is incorrect. TPN may cause an increase in blood sugar levels in the first 48 hours of administration as the client has not yet adjusted to the glucose load of the patient. However, since it is already two weeks of administering the solution, the client should have already changed to the TPN solution.

Which of the following statements should the nurse use to best describe a very low-calorie diet? A. "This is a long-term treatment measure that assists obese people who can't lose weight." B. "A VLCD contains very little protein." C. "This diet can be used only when there is close medical supervision." D. "This diet consists of solid food that is pureed to facilitate digestion and absorption." Submit Answer

Explanation Choice C is correct. Very Low-Calorie Diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3-5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and the risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3-4 months. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months and gaining all of the weight back in less than five years. Low-calorie diets (LCDs) are not as extreme and with almost twice as many calories allowed (1200-1500 kcal/day), the weight loss is modest. Choice A is incorrect. The VLCD is not intended to be a long-term treatment measure. Choice B is incorrect. VLCD consists of high levels of quality proteins. Choice D is incorrect. The food on a VLCD is not pureed. Last Updated - 27, Jan 2022

A patient presents with weight loss and diarrhea with frothy, fatty, foul-smelling, yellow-gray stools. Which of the following malabsorption issues would not be a possible cause? A. Pancreatitis B. Celiac disease C. Lactose intolerance D. Tropical sprue

Explanation Choice C is correct. Weight loss and diarrhea are general signs and symptoms of most malabsorption disorders and are not specific enough symptoms to differentiate these disorders. Therefore, the critical symptom is the frothy, fatty, foul yellow-gray stools (steatorrhea). Steatorrhea may occur in all of the other answer choices listed but is not seen in lactose intolerance. Choice A is incorrect. Steatorrhea is caused by the presence of undigested, unabsorbed fat. Steatorrhea, infection, and diabetes are signs that pancreatic damage is worsening. Choice B is incorrect. The most common signs/symptoms of celiac disease are diarrhea, flatulence, abdominal distention, and malnutrition symptoms such as weight loss and steatorrhea. Choice D is incorrect. Tropical sprue refers to bacterial proliferation that is common in tropical regions and causes chronic/progressive damage to jejunal and ileal tissues. Steatorrhea may occur as a result of the damage to these tissues and malabsorption. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: Elimination, nutrition, and oral hydration Last Updated - 01, Nov 2021

During a physical assessment, the nurse inspects the patient's abdomen. What assessment technique would the nurse perform next? A. Percussion B. Palpation C. Auscultation D. Whichever is most comfortable for the patient

Explanation Choice C is correct. When performing a physical assessment, the most often used sequence is: Inspection Palpation Percussion Auscultation However, palpation and percussion can alter bowel sounds. Therefore, for abdominal assessments, the steps should be: Inspect Auscultate Percuss Palpate Choices A, B, and D are incorrect. When assessing the abdomen, auscultation should occur after inspection. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Types of Assessments Last Updated - 17, Jan 2022

When assessing a patient with nausea, vomiting, and diarrhea, which of the following focused assessment techniques should the nurse use? A. Evaluate for dehydration, assess skin turgor, auscultate lungs B. Auscultate lungs, auscultate heart, auscultate abdomen C. Auscultate abdomen, palpate the abdomen, evaluate for dehydration D. Palpate the abdomen, percuss the abdomen, auscultate heart

Explanation Choice C is correct. With the presence of nausea, vomiting, and diarrhea, the concern arises about fluid volume deficit and the potential for dehydration, which would be noted with poor skin turgor. The abdomen should be auscultated to evaluate for suspected hyperactive sounds due to the increased peristalsis. Choices A and B are incorrect. The lungs are not grouped with the symptoms presented. Choice D is incorrect. Auscultating the heart is an option to determine heart rate, but an increased heart rate can be evaluated when vital signs are collected. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Objective Data Collection Last Updated - 10, Jan 2022

Which screening tool would you use to screen clients for their current nutritional status? A. The Klein-Bell Scale B. The Barthel Index C. The Wong-Baker Assessment tool D. The Patient Generated Subjective Global Assessment

Explanation Choice D is correct. The Patient-Generated Subjective Global Assessment is a screening tool you would use to screen clients for their current nutritional status. The Patient-Generated Subjective Global Assessment, referred to as the PG-SGA nutritional assessment, is an assessment tool that can be used to assess nutritional status, among others, such as the Nutritional Screening Initiative screening and assessment tool. Choice A is incorrect. The Klein-Bell Scale is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice B is incorrect. The Barthel Index is used to perform a neurological and musculoskeletal assessment, not a nutritional screening or evaluation. Choice C is incorrect. The Wong-Baker assessment tool is a pain assessment tool, not a nutritional screening or assessment tool. Last Updated - 24, Jan 2022

Total parenteral nutrition (TPN) is being considered for your client. Your client tells you, "My doctor is thinking about hyperalimentation, and I know nothing about it. Can you tell me what it is?". You should respond to this client's statement with: A. "Your doctor is thinking about total parenteral nutrition and not hyperalimentation." B. "Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube." C. "Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." D. "You should choose to have enteral nutrition and not accept hyperalimentation."

Explanation Choice C is correct. You should respond to this client's statement with, "Hyperalimentation is one kind of parenteral nutrition that gives you feedings with a special IV line." Parenteral nutrition, which is synonymous with hyperalimentation and IV hyperalimentation, provides the client with complete food when it is indicated for a client such as one who is adversely affected Choice A is incorrect. You should not respond to this client's statement with, "Your doctor is thinking about total parenteral nutrition and not hyperalimentation" because parenteral nutrition is hyperalimentation; parenteral nutrition is synonymous with hyperalimentation and IV hyperalimentation. Choice B is incorrect. You should not respond to this client's statement with, "Hyperalimentation is one kind of enteral nutrition that gives you feedings with a tube" because hyperalimentation is parenteral nutrition and not enteral nutrition. Choice D is incorrect. You should not respond to this client's statement with, "You should choose to have enteral nutrition and not accept hyperalimentation" because this is coercive and contrary to the client's right to make an informed decision about any or all care that is being considered.

You are caring for a female client who is 5 foot 2 inches tall and has a BMI of 17. This client is now on a regular diet. You would most likely recommend: A. Continuing their diet as it is B. Weight reduction with diet and exercise C. A high caloric diet to gain weight D. Nothing at all, this client is normal

Explanation Choice C is correct. You would most likely recommend a high caloric diet to gain weight for this client, who is 5 foot 2 inches tall and has a body mass index (BMI) of 17 because this client is underweight. The ranges for BMI are as follows: Underweight: Under 18.5 Normal: From 18.5 to 24.9 Overweight: From 25 to 29.9 Obesity: From 30 to 39.9 Extreme obesity: Over 40 Choice A is incorrect. A body mass index (BMI) of 17 indicates the need for dietary intake to gain weight. Choice B is incorrect. You would not advise the client to begin a weight reduction diet because a body mass index (BMI) of 17 indicates the need for education about dietary intake to gain weight. Choice D is incorrect. A body mass index (BMI) of 17 indicates the need for dietary intake to gain weight. Last Updated - 14, Oct 2021

Which of the following clients is the most likely to receive total parenteral nutrition? A. A client who is adversely affected with dysphagia. B. A client who is adversely affected with aphasia. C. A client with a dangerous positive nitrogen balance. D. A client with a dangerous negative nitrogen balance.

Explanation Choice D is correct. A client with a dangerous negative nitrogen balance is most likely to receive total parenteral nutrition (TPN). For example, a client who has endured a severe burn injury may have a negative nitrogen balance, which requires the administration of total parenteral nutrition. Amino acids are building blocks of proteins and nitrogen is an essential component of amino acids. Therefore, protein metabolism can be determined by measuring nitrogen balance. Nitrogen balance is given by subtracting nitrogen output from nitrogen input. A negative balance means the amount lost is greater than the amount ingested. A negative nitrogen balance is used to assess malnutrition. Clients with severe negative nitrogen balance will benefit from total parenteral nutrition. Other conditions where total parenteral nutrition is indicated include advanced cancer, advanced acquired immunodeficiency disorder, and severe gastrointestinal disease, which requires complete bowel rest. Choice A is incorrect. A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia. Choice B is incorrect. A client who is adversely affected with aphasia would not likely receive parenteral nutrition. A client who is negatively affected by aphasia has a communication disorder, rather than a nutritional disease or nutritional need. Choice C is incorrect. A client with a dangerous positive nitrogen balance would not be likely to receive parenteral nutrition to meet their nutritional needs. Additional protein is not necessary.

The nurse is discharging a client with a new sigmoid colostomy. Which statement from the client indicates a need for further teaching? A. "I will call my doctor immediately if my stoma becomes bluish." B. "I can eat what I used to eat when I go back home." C. "I need to wear a pouch over my stoma." D. "I need to irrigate my colostomy every week with tap water."

Explanation Choice D is correct. A colostomy should be irrigated daily (not weekly) so that the client will have a daily bowel movement. This statement signifies the client needs more teaching. Choice A is incorrect. Bluish discoloration of the stoma indicates necrosis and requires immediate action. The client needs to call the physician when this happens. The color of a normal, healthy stoma should be reddish to pink. Choice B is incorrect. The client can go back to her regular diet once she is discharged as the stoma is already working. Choice C is incorrect. A colostomy pouch should be worn over the stoma to collect the feces that is coming out of the stoma. Last Updated - 01, Sep 2021

Which assessment data would the nurse recognize as a sign that a patient may have a duodenal ulcer? A. Gaseous pressure in the upper left abdomen B. Abdominal discomfort worsens 1-2 hours after eating C. 10 pound weight loss in the past 6 months D. Episodic stomach pain 2-4 hours after meals

Explanation Choice D is correct. Abdominal discomfort due to a duodenal ulcer is typically the worst 2-4 hours post meals and is periodic/episodic. Choice A is incorrect. Burning or gaseous pressure in the high left epigastrium, back, and upper abdomen describes common symptoms of a gastric ulcer. Choice B is incorrect. Abdominal pain worsens within 1-2 hours of meals for gastric ulcers. Choice C is incorrect. Nausea, vomiting, and weight loss are associated with gastric ulcers. NCSBN Client Need Topic: Adult health - Gastrointestinal, Subtopic: Elimination, nutrition and oral hydration, system-specific assessments, illness management, pathophysiology Last Updated - 15, Feb 2022

The nurse is caring for a client with Helicobacter pylori. The nurse should anticipate a prescription for which of the following medications? A. Dicyclomine B. Metoclopramide C. Valacyclovir D. Amoxicillin

Explanation Choice D is correct. Amoxicillin is an antibiotic that is commonly used to treat Helicobacter pylori infections. When treating this infection, this medication is often coupled with a proton pump inhibitor such as esomeprazole. Choices A, B, and C are incorrect. Dicyclomine is an antispasmodic medication used to treat gastrointestinal spasms, which are common in individuals with irritable bowel syndrome. Metoclopramide is a medication that causes gastric emptying and is used for nausea and vomiting. Valacyclovir is an antiviral indicated for herpes infections.

A client recently diagnosed with peptic ulcer disease is being discharged. While the nurse provides discharge teaching, which of the following over-the-counter medications should the client be instructed to avoid? A. Calcium B. Magnesium C. Sodium D. Aspirin

Explanation Choice D is correct. Aspirin disrupts the normal mucosal defense and repair, making the mucosa more susceptible to acid. The nurse should instruct this client on the importance of avoiding aspirin and all other nonsteroidal anti-inflammatories (NSAIDs) now and in the future. Choice A is incorrect. There is no need to instruct this client to avoid over-the-counter calcium. Choice B is incorrect. There is no need to instruct this client to avoid over-the-counter magnesium. Choice C is incorrect. There is no need to instruct this client to avoid over-the-counter sodium. Learning Objective Identify the need to instruct a newly diagnosed peptic ulcer disease client to avoid the use of aspirin and all other nonsteroidal anti-inflammatory (NSAID) medications. Additional Info Most ulcers are caused by H. pylori infection or nonsteroidal anti-inflammatory drug use. Acute complications of peptic ulcer disease include gastrointestinal bleeding and perforation. Chronic complications of peptic ulcer disease include gastric outlet obstruction, recurrence, and, when H. pylori infection is the cause, stomach cancer.

The nurse is talking to a patient that just had an ileostomy created a month ago. He states that he is a bit embarrassed by the odor that the ostomy is producing. The nurse investigates the food that the client consumes and initiates further health teaching when the client mentions the following menu: A. Spinach B. Parsley C. Yogurt and buttermilk D. Eggs

Explanation Choice D is correct. Eggs, fish, onions, cabbage, and some greens produce foul-smelling stools. Clients are advised to avoid these foods to eliminate foul odors in their ileostomy. Choice A is incorrect. Spinach is a deodorizing food for clients with an ileostomy. Choice B is incorrect. Parsley is a deodorizing food for clients with an ileostomy. Choice C is incorrect. Yogurt and buttermilk are deodorizing food for clients with an ileostomy. Last Updated - 10, May 2021

The nurse is providing health education on a client with dumping syndrome. Which teaching point about drinking fluids is accurate? A. The client should drink fluids immediately before meals B. The client must only drink fluids with meals C. The client must drink fluids before and during meals D. The client should drink fluids at least a half an hour after meals

Explanation Choice D is correct. Fluids should be taken at least 30 minutes to 1 hour after meals to avoid dumping syndrome. Choices A, B, and C are incorrect. Fluids consumed at the same time as food increase the speed of gastric emptying, subsequently increase the likelihood of dumping syndrome. Last Updated - 15, Feb 2022

The physician places an order to administer gentamicin via IV for a client with acute diverticulitis. It is important for the nurse to know that IV gentamicin is administered: A. Over 1 minute as I.V. push B. Over 2 minutes as I.V. push C. As an I.V. side drip over 15-20 minutes D. As an I.V. side drip over 30-60 minutes Submit Answer

Explanation Choice D is correct. Gentamicin is an aminoglycoside that is nephrotoxic. Because of this, it should be administered slowly by intermittent infusion. The recommended duration of infusion for administration is 30-60 minutes. Choices A, B, and C are incorrect. It is not encouraged to be operated by bolus or I.V. push. Last Updated - 01, Feb 2022

A nurse is taking care of a client with acute peritonitis. The nurse's focus of care is the client's nutritional needs. To meet this, the nurse should do which of the following? A. Administer feedings via NGT B. Administer gastric enteral feedings C. Feed the client orally D. Administer parenteral feedings

Explanation Choice D is correct. In clients with peritonitis, it is recommended to give the GI tract time to rest and recover. Food is not administered through the GI tract. Clients with peritonitis are typically fed parenterally via TPN or peripheral parenteral nutrition. Choices A, B, and C are incorrect. Last Updated - 03, Feb 2022

What is the correct sequence when performing an abdominal assessment? A. Auscultation, inspection, palpation, percussion B. Inspection, palpation, percussion, auscultation C. Palpation, percussion, inspection, auscultation D. Inspection, auscultation, percussion, palpation

Explanation Choice D is correct. Inspection is always performed first. Auscultation of the abdomen must be performed before percussion and palpation to prevent the alteration of bowel sounds. Choices A, B, and C are incorrect. Performing percussion and palpation before auscultation may cause falsely increased bowel sounds by stimulating bowel activity. An inspection does not interfere with the rest of the abdominal exam. Therefore, inspection should be performed first, followed by auscultation, percussion, and palpation. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Abdominal Assessment Learning Objective The correct abdominal examination sequence differs from other areas, such as the lungs. The auscultation component in an abdominal exam should precede percussion and palpation.

A patient receiving intermittent feedings through a nasogastric tube must have their residual volumes checked before administering more formula. Which is the best rationale for checking residual capacity? A. Evaluate electrolyte status B. Observe the color of the stomach contents C. Confirm placement of the nasogastric tube D. Evaluate absorption from the last feeding

Explanation Choice D is correct. Stomach contents should be aspirated before administration of the next feeding to ensure absorption is occurring as expected. Overfilling a stomach could lead to enlargement and increased risk of aspiration. Choice A is incorrect. Checking residual volume will not aid a nurse in evaluating a patient's electrolyte status. Choice B is incorrect. While the nurse needs to note the color of the residual volume to rule out any abnormal findings, such as frank bleeding, this is not the best rationale for checking residual capacity. Choice C is incorrect. Confirming nasogastric tube placement is an essential step in administering more formula to a patient. However, it is not the best reason for checking residual volume. NCSBN Client need Topic: Reduction of Risk Potential / Potential for Complications of Diagnostics Tests, Treatments or Procedures Last Updated - 20, Dec 2021

Which of these interventions is the priority when caring for a patient experiencing an exacerbation of inflammatory bowel disease who is to receive total parenteral nutrition and lipids? A. Infuse the solution in a large peripheral vein B. Monitor urine specific gravity every shift C. Change the administration set every 72 hours D. Monitor the patient's blood glucose per protocol

Explanation Choice D is correct. TPN can cause hyperglycemia, so blood glucose levels should be closely monitored. Parenteral nutrition, or intravenous feeding, is a method of getting food into the body through the veins. Depending on which thread is used, this procedure is often referred to as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN). Parenteral nutrition is used to help people who can't or shouldn't get their core nutrients from food. It's often used for people with: Irritable Bowel or Crohn's disease Cancer Short bowel syndrome Ischemic bowel disease It also can help people with conditions that result from low blood flow to the bowels. Parenteral nutrition delivers nutrients such as sugar, carbohydrates, proteins, lipids, electrolytes, and trace elements to the body. These nutrients are vital in maintaining high energy, hydration, and strength levels. The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin changes. You should speak with your doctor if these conditions don't go away. Other less common side effects include: changes in heartbeat confusion convulsions or seizures difficulty breathing fast weight gain or weight loss fatigue fever or chills increased urination jumpy reflexes memory loss muscle twitching, weakness, or cramps stomach pain swelling of your hands, feet, or legs thirst tingling in your hands or feet vomiting Choice A is incorrect. Due to the hypertonicity of the TPN solution, it must be administered via a central venous catheter. Choice B is incorrect. This is not the primary nursing intervention. Choice C is incorrect. The high glucose and lipids make the TPN an excellent medium for bacterial growth, so administration sets should be changed every 24 hours if the TPN contains fats. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort, Enteral Nutrition

The nurse is positioning a client following a liver biopsy. Which position is best suited for this client? A. On the left side with a pillow under the ribs. B. Supine with a pillow under the client's knees. C. Face down with a pillow under the hips. D. On the right side with a pillow under the biopsy site. Submit Answer

Explanation Choice D is correct. The client should lay on the right side with a pillow against the biopsy site at the right costal margin. Following the liver biopsy, the right lateral decubitus position reduces the risk of post-biopsy bleeding by putting pressure on the liver biopsy site. Choice A is incorrect. Clients who have just had a liver biopsy should maintain pressure on the biopsy site. Laying laterally on the left side with a pillow underneath the ribs does not provide enough support to the actual location of the liver biopsy because the liver is located on the right side. Choice B is incorrect. The supine with a pillow under the client's hips is not the best. This position does not provide any support to the site of the liver biopsy. Choice C is incorrect. Facedown, or prone, is not an appropriate way to lay after a liver biopsy.

The nurse is in charge of a male client scheduled for a liver biopsy at 8 AM. In preparing this client for the procedure, the nurse should do which of the following? A. Inform the client that he will be kept NPO for 24 hours before the biopsy. B. Let the client practice holding his breath for 1 minute. C. Inform the client that he will be receiving a laxative to prevent bowel distention as this can apply pressure on the liver. D. Inform him that his vital signs will be monitored closely after the procedure.

Explanation Choice D is correct. The client will be monitored closely for bleeding and shock after the procedure. It is appropriate to monitor vital signs. Choices A, B, and C are incorrect. The preparation for a liver biopsy does not include placing the client on NPO, nor administration of a laxative. The client will be asked to hold his breath but only for 5-10 seconds.

When providing bowel training education to a 65-year-old woman with chronic constipation. Which of the following indicates that the nurse needs to continue gathering information? A. The client's fluid intake is between 2500-3000 mL per day. B. The client's dietary habits include foods high in bulk. C. The client engages in moderate exercise each day. D. The client states that she can use a laxative 4-5 times weekly until bowel regularity is achieved. Submit Answer

Explanation Choice D is correct. The consistent use of laxatives inhibits natural defecation reflexes and is thought to cause, rather than cure, constipation. The frequent user of laxatives eventually requires larger or stronger doses because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of specific vitamins. The reasons for constipation can range from lifestyle habits (e.g. lack of exercise) to severe malignant disorders (e.g. colorectal cancer). The nurse should evaluate any complaints of constipation carefully for each individual. A change in bowel habits over several weeks with or without weight loss, pain, or fever should be referred to a primary care provider for a complete medical evaluation. See clinical manifestations for risk factors and symptoms of colorectal cancer. Choices A, B, and C are incorrect. These are all measures that help promote healthy bowel habits and indicate that the client understands steps to help reduce constipation. Adequate fluid intake helps prevent dry, hard stools. High bulk in the diet helps promote the absorption of water. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Basic Care and Comfort Last Updated - 16, Feb 2022

The nurse is preparing a client with peptic ulcer disease for a barium study of the stomach and esophagus. What should be the initial nursing action? A. Have the informed consent signed by the client for the procedure. B. Teach the client the importance of increased oral fluids after the procedure. C. Explain to the client that he or she will have to drink a white, chalky substance. D. Instruct the client not to eat or drink anything before the procedure. Submit Answer

Explanation Choice D is correct. The first or initial intervention for the nurse is to inform the client that he or she needs to be on NPO at least 8 to 10 hours before the test. The barium study requires the upper GI tract to be empty during the procedure. Choice A is incorrect. A barium study is a non-invasive procedure and does not require an informed consent form. Choice B is incorrect. A side effect of barium is constipation after the procedure. The nurse, therefore, needs to instruct the client to drink lots of fluids. It is not, however, the initial intervention of the nurse. Choice C is incorrect. The client needs to know that he will need to drink the barium, which is a white and chalky substance during the procedure. However, this is not the initial nursing intervention. Last Updated - 24, Jan 2022

The nurse is caring for a 4-day post-abdominal surgery client. The nurse notes a temperature of 37 °C, no complaints of pain at the incision site, dry wound dressing, and hypoactive bowel sounds on all quadrants. Which conclusion can the nurse make based on all the assessment data? A. The client's wound is getting infected. B. The nurse should implement pain relief measures. C. There are no present problems for the client. D. The nurse should perform an additional GI assessment. Submit Answer

Explanation Choice D is correct. The nurse should use all the data gathered to analyze the situation. The client had abdominal surgery and has hypoactive bowel sounds. The nurse needs to do a further assessment to determine if there are any impending GI problems for the client and if any treatments need to be initiated. Choice A is incorrect. The client's wound dressing is dry and intact. The client is not hysterical. There is no sign of infection. Choice B is incorrect. The client states that he is not in pain; there is no need for pain relief. Choice C is incorrect. The client is four days post-op; the client is already expected to have normoactive bowel sounds. However, the client is exhibiting hypoactive bowel sounds, which signifies a problem. Last Updated - 02, Nov 2021

Which of the following statements about appendicitis are true? Select all that apply. A. McBurney's point tenderness is a sign of appendicitis. B. Appendicitis is more common among males. C. A low carbohydrate diet is a risk factor for appendicitis. D. Lower left quadrant pain is a sign of appendicitis.

Explanation Choices A and B are correct. McBurney's point tenderness refers to right lower quadrant pain; this is suggestive of appendicitis (choice A). Appendicitis is more common amongst males than females (choice B). Choice C is incorrect. A high carbohydrate diet, or a low fiber diet, are risk factors for appendicitis. Choice D is incorrect. Lower right quadrant pain is concerning for appendicitis, not left.

Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube? A. A 9-year-old client with a femur fracture. B. An 82-year-old client with congestive heart failure. C. A 65-year-old client on dialysis. D. A 52-year-old client with leukemia who is receiving chemotherapy.

Explanation Choice D is correct. The nurse suspects that a 52-year-old female with leukemia receiving chemotherapy would benefit most from a nasogastric tube. Nasogastric tubes are placed to help clients meet their nutritional needs. A client with leukemia has an increased need for calories and protein, but the chemotherapy treatment she is undergoing is likely to cause anorexia and nausea. This client could benefit from a nasogastric tube to help meet her nutritional needs. Choice A is incorrect. A client with a femur fracture does not have a specific need that would cause them to benefit from a nasogastric tube. This client should not have any difficulty meeting nutritional needs by mouth. Choice B is incorrect. Clients with congestive heart failure have no specific need that would cause them to benefit from a nasogastric tube. This is a chronic diagnosis that requires complex medical management, but this type of client is typically able to meet their nutritional needs by mouth. Choice C is incorrect. Clients on dialysis have no specific need that would cause them to benefit from a nasogastric tube. They are typically able to meet their nutritional needs by mouth. Many clients who live with a fistula receive dialysis either at home or in a treatment center regularly while maintaining their normal life. Last Updated - 31, Jan 2022

Which of the following nursing diagnoses is appropriate for a client who has serum albumin of 2.8 g/dL and serum prealbumin of 17? A. At risk for renal calculi related to the albumin and prealbumin levels. B. At risk for hyperalbuminemia related to the albumin and prealbumin levels. C. At risk for hypoalbuminemia related to the albumin and prealbumin levels. D. At risk for the loss of muscle mass related to the albumin and prealbumin levels.

Explanation Choice D is correct. The nursing diagnosis that is appropriate for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 is "at risk for the loss of muscle mass related to the albumin and prealbumin levels." These levels indicate that the client is affected by low albumin levels (hypoalbuminemia). Hypoalbuminemia can lead to the loss of muscle mass, poor wound healing, and other complications. Choice A is incorrect. "At risk for renal calculi related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17. There is no relationship between albumin and prealbumin levels and the formation of renal calculi. Choice B is incorrect. "At risk for hyperalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels do not indicate high albumin. Choice C is incorrect. "At risk for hypoalbuminemia related to the albumin and prealbumin levels" is not an appropriate nursing diagnosis for a client with serum albumin of 2.8 g/dL and serum prealbumin of 17 because these levels indicate the need for an actual nursing diagnosis, rather than a potential "at-risk" nursing diagnosis. Last Updated - 05, Feb 2022

The nurse is caring for a patient with post-gastrectomy dumping syndrome. What teaching should the nurse provide for this patient? A. Take small sips of water during meals to soften the food for easier digestion. B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery. C. Plan rest periods of 10-15 minutes after every meal. D. Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content.

Explanation Choice D is correct. The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands. Choice A is incorrect. Patients experiencing dumping syndrome should be instructed to avoid drinking during meals to prevent fullness and distention. Patients should drink in between meals at least 30-45 minutes before or after eating. Choice B is incorrect. Symptoms of dumping syndrome generally resolve in several months to a year after gastrectomy surgery. Choice C is incorrect. Post-meal rest periods should be at least 30 minutes to allow enough time for the digestion process to begin. NCSBN Client Need Topic: Adult health, Subtopic: Gastrointestinal/nutrition Last Updated - 27, Jan 2022

A 62-year-old man with right shoulder pain starts noticing that his stool is clay-colored. He's never been a heavy drinker and has no known liver issues. What test should the nurse expect the doctor to order first while waiting for an ultrasound? A. Creatinine and BUN blood levels B. Serial abdominal exams C. ERCP D. Bilirubin level

Explanation Choice D is correct. The physician will want to know the patient's bilirubin level since it will be elevated. Increased bilirubin levels are associated with liver disease because the liver creates bilirubin. When it's not able to filter it out of the blood, it builds up. Choice A is incorrect. These lab values are helpful in kidney disease, not liver disease. Choice B is incorrect. Serial abdominal exams will not be a practical assessment in the care of this patient at this time. Choice C is incorrect. An ERCP (endoscopic retrograde cholangiopancreatography) may be warranted, but the doctor will want a more definitive diagnosis before sending the patient to surgery. NCSBN Client Need Topic: Safe and Effective Care Environment, Sub-topic: Care Management, Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder Last Updated - 16, Feb 2022

While orienting a new graduate nurse in the ICU, you take care of a patient scheduled for peritoneal dialysis. Which of the following principles do you explain to the new graduate about peritoneal dialysis functions? Select all that apply. A. Osmosis B. Diffusion C. Oncotic pressure D. Osmotic pressure Submit Answer

Explanation Choices A and B are correct. Osmosis is an essential principle upon which peritoneal dialysis functions. Osmosis is the passive movement of solvents, such as water, across a permeable membrane. The peritoneum is a permeable membrane. (Choice A). Diffusion is an essential principle upon which peritoneal dialysis functions. Distribution is the passive movement of solutes across a membrane. Solutes diffuse from an area of higher concentration to an area of lower concentration, across the peritoneum, until there is an equal amount of each on both sides of the membrane (Choice B). Choice C is incorrect. The oncotic pressure is a form of osmotic stress induced by proteins in a blood vessel's plasma that displaces water molecules. This is not an essential principle upon which peritoneal dialysis is based. Choice D is incorrect. Osmotic pressure is the pressure that would have to be applied to a pure solvent to prevent it from passing into a given solution by osmosis. This is not an essential principle upon which peritoneal dialysis is based. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological Adaptation, Renal Last Updated - 06, Sep 2021

You are caring for a 65-year-old female patient in the surgical unit. She had an ileostomy two days ago and had ongoing nausea and vomiting since then. She has an NG tube in place set to low, intermittent suction. She is weak and has muscle spasms. Her electrolytes show low potassium and calcium levels. Her blood pressure is 165/80 mmHg, and her heart rate is 85. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.50 PaCO2 = 42 Bicarbonate = 35 You determine that this ABG shows: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Explanation Choice D is correct. This ABG shows metabolic alkalosis. The first clue in this patient is the diagnosis of ileostomy and continuous NG suction from the stomach. When a patient's stomach contents are removed through vomiting or suctioning, acidic gastric secretions are lost, and bicarbonate ions begin to accumulate in the extracellular space. The registered nurse must know the basics of ABG interpretation, including the normal ranges for each of the values. First, the nurse should look at the pH. The normal range is 7.35-7.45. A value below 7.35 indicates an acidosis; a value above 7.45 indicates an alkalosis. The normal partial pressure of carbon dioxide (PaCO2) is 35-45 mmHg. Standard bicarbonate for a woman this age is 22-29 mmol/L. The pH in this patient shows that the condition is alkalosis. The high bicarbonate indicates that it is a primary metabolic problem. These values would support the assumption of metabolic alkalosis based on the diagnosis of ileostomy, nausea, vomiting, and gastric suction. The respiratory system begins to compensate very quickly when metabolic alkalosis develops. It is not unusual to see an increased PaCO2 in metabolic alkalosis as the body attempts to correct the underlying alkalosis. Respiratory disorders are defined by the pH and the PaCO2. Respiratory acidosis is defined as a pH below 7.35 and a PaCO2 above 45 mmHg. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mmHg. Metabolic disorders are defined by the pH and the bicarbonate (HCO3). Metabolic acidosis is defined as a pH below 7.35 and an HCO3 below 22 mmol/L. Metabolic alkalosis is defined as a pH above 7.45 and an HCO3 above 29 mmol/L Choices A, B, and C are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-Topic: Fluid and Electrolyte Imbalances, Gastrointestinal/Nutritional Last Updated - 20, Jan 2022

A client arrives to the emergency department (ED) with complaints of vomiting for three days. The client's spouse reports the client has been getting progressively weaker with increasing dyspnea. The nurse notes that the client's respiratory rate is ten (10) breaths/min. An electrocardiogram (ECG) indicates tachycardia with a heart rate of 120 beats/min. Arterial blood gases (ABG) are subsequently ordered and drawn. When reviewing the ABG results, the nurse should anticipate which of the following? A. A decreased pH and an elevated CO2 B. An elevated pH and a decreased CO2 C. A decreased pH and a decreased HCO3- D. An increased pH with an increased HCO3-

Explanation Choice D is correct. This client has presented with one of the most common causes of metabolic alkalosis: Persistent nausea and vomiting leading to metabolic alkalosis due to the loss of gastric acid, therefore causing an increase in the pH and HCO3-. Hypoventilation and tachycardia are some symptoms the client may experience. Tachycardia occurs from volume depletion, while decreased respiratory effort may be associated with skeletal muscle weakness related to the metabolic alkalosis. Choice A is incorrect. This type of result would be indicative of a client experiencing respiratory acidosis. Choice B is incorrect. This type of result would be indicative of a client experiencing respiratory alkalosis. Choice C is incorrect. This type of result would be indicative of a client experiencing metabolic acidosis. Learning Objective Correlate the client's symptoms with a likely diagnosis of metabolic alkalosis; recognizing the client's arterial blood gas sample will return a result demonstrating increased pH and HCO3- levels. Additional Info Metabolic alkalosis is bicarbonate (HCO3-) accumulation due to acid loss, alkali administration, intracellular shift of hydrogen ion, or renal HCO3- retention. Metabolic alkalosis involving loss or excess secretion of chloride is termed chloride-responsive. Treatment of chloride-responsive metabolic alkalosis clients includes addressing the root cause of the imbalance and intravenous infusions of 0.9% saline. Chloride-resistant metabolic alkalosis is due to increased aldosterone effect. Treatment of chloride-resistant metabolic alkalosis clients involves the correction of hyperaldosteronism.

The nurse is caring for a client with total parenteral nutrition. Which assessment findings would warrant immediate action by the nurse? A. The patient complains of dry skin and thirst B. A temperature of 37° degrees C C. Blood pressure of 116/74 mmHg D. Blood sugar level of 362 mg/dL Submit Answer

Explanation Choice D is correct. This is an elevated blood sugar level. This may be due to the TPN's high glucose content which the client is still adjusting to. The nurse should immediately notify the physician to initiate the medical management of hyperglycemia. Choice A is incorrect. Dry skin and thirst may be a sign leading to dehydration. The nurse may increase the client's fluids but it is not a priority action. Choice B is incorrect. This is a normal temperature. There is no need for intervention. Choice C is incorrect. This is normal blood pressure. There is no need for intervention.

The nurse is caring for a 26-year-old patient who is unable to meet their nutritional needs by mouth. The interdisciplinary team decides it would be best to insert an NG tube for enteral feedings. After inserting the tube, the nurse knows that which of the following is the most accurate way to verify the placement of the tube? A. Aspiration of stomach contents B. pH verification of the aspirate C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ) D. Visualization on an x-ray Submit Answer

Explanation Choice D is correct. Visualization on an x-ray is the gold standard for verification of nasogastric tube placement. This allows the radiologist to visualize the tip of the tube in the stomach and recommend any changes in placement that may be needed, such as pulling the tube back or advancing further. Choice A is incorrect. The aspiration of stomach contents is one way the nurse can independently check the placement of a nasogastric tube, but it is not the most reliable indicator. Visualization on x-ray is considered the "gold standard" for verification of tube placement. Choice B is incorrect. A pH verification of the aspirate is not always accurate. Although a pH lower than 4.5 may suggest stomach contents being aspirated from the nasogastric tube, it is important to recognize that multiple other factors such as the tube feed formula and prescribed medications may also affect the pH. Since these factors can cause variable pH, it is not considered a reliable method of verifying nasogastric tube placement. Choice C is incorrect. Auscultation of air in the LUQ, when injected into the tube, is an old practice that is no longer recommended as a reliable nasogastric tube placement verification method. Air auscultation is highly subjective and can sometimes be appreciated even if the tube was incorrectly placed into the lungs. It is even more challenging on smaller-sized pediatric patients, as the sound of the air can resonate throughout their abdomen and thorax, making it impossible to verify the nasogastric tube placement. NCSBN Client Need Topic: Health promotion and maintenance, Subtopic: GI/nutrition Last Updated - 15, Feb 2022

The nurse is caring for a client receiving total parenteral nutrition (TPN) started twelve hours ago. The priority assessment should be the client's A. urine output. B. oral temperature. C. weight. D. capillary blood glucose.

Explanation Choice D is correct. When TPN is initially started, an increase in blood glucose may be observed. The client's blood glucose should be monitored every 4-6 hours, and insulin coverage may be prescribed. Further, regular insulin may be added to the bag of TPN (by the pharmacy) if the client's blood glucose continues to be elevated. Choices A, B, and C are incorrect. Urine output is not critical to monitor during the course of TPN. For the nurse to determine if the TPN is being effective, the client should have their daily weight obtained. Urine output is a crude way of measuring fluid status pertaining to TPN. TPN solution is an excellent medium for bacterial growth. The client is at high risk for a central line associate bloodstream infection (CLABSI), but this would not manifest within the first twelve hours of the infusion. Weight should be monitored for a client receiving TPN; however, a weight shift is not expected within the first twelve hours, and the most likely complication would be hyperglycemia. TPN is a risk factor for infection as the high glucose content makes the client more likely to develop a bacterial or fungal infection. During an infusion of TPN, the nurse should monitor the client's vital signs and blood glucose. Hyperglycemia may delay healing and should be managed with a prescribed insulin protocol.

The nurse is caring for a client receiving intermittent bolus tube feedings. The nurse prepares to begin the next feed but first aspirates 85 mL of residual from the nasogastric tube. Following the aspiration, which of the following actions by the nurse are correct? Select all that apply. A. Document the color, odor, consistency, and amount of the residual. B. Hold the next feeding. C. Send the residual to the lab. D. Administer the residual back to the patient. E. Administer the feeding, but subtract the quantity of the residual from the feed.

Explanation Choices A and D are correct. A is correct. This is the appropriate documentation for any fluids the nurse observes from her patient. You can remember this documentation from the mnemonic COCA: color, odor, consistency, and amount. For example, in this situation, it may be tan, formula-like residual, non-odorous, thick, 85 mL. This documentation will help identify what is normal for the client and when there are any issues. D is correct. The nurse should administer the residual back to the client. This is incredibly important for the prevention of electrolyte imbalances. The stomach contents are rich in many electrolytes, such as potassium and chloride. Removing the stomach contents and not returning them to the client could create dangerous electrolyte abnormalities. Choice B is incorrect. When less than 500 mL of residual is aspirated, and if there are no signs of feeding intolerance, it is not necessary to hold the next feeding. If the aspirate is less than 250 mL, the aspirate should even be returned to the client. Choice C is incorrect. It is not necessary to send the residual to the lab. The residual should be returned to the client. Choice E is incorrect. The nurse should not subtract the quantity of the residual from the feed. When less than 500 mL of residual is aspirated, the total feeding amount continues as scheduled unless there are any signs of feeding intolerance.

You are working in the emergency department and are preparing to discharge a patient who came in with a magnesium level of 1.4 mEq/L. You are writing a list of foods you recommend that the patient consumes. Which foods would be appropriate for this list? Select all that apply. A. Spinach B. Onions C. Mushrooms D. Salmon

Explanation Choices A and D are correct. This patient's magnesium level is borderline low, so the nurse must encourage them to eat foods rich in magnesium. Spinach is an excellent source of magnesium, offering about 140 mg per cup (Choice A). Salmon is a good source of magnesium, offering about 88 mg per fillet (Choice D). Choice B is incorrect. This patient's magnesium level is borderline low, so the nurse must encourage them to eat foods rich in magnesium. Onions are not a good source of magnesium, as they only have about 3 mg per cup. Choice C is incorrect. This patient's magnesium level is borderline low, so the nurse must encourage them to eat foods rich in magnesium. Mushrooms are not a good source of magnesium, as they only have about 7 mg per cup. NCSBN Client Need: Topic: Health promotion and maintenance, Subtopic: Nutrition Last Updated - 15, Nov 2021

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply. A. Hyperglycemia B. Infection C. Air embolism D. Cardiac tamponade E. Dehydration

Explanation Choices A, B, C, and E are correct. The base solution of TPN is dextrose 50%, and this concentrate will increase blood glucose levels. Hyperglycemia (blood glucose > 250 mg/dL) is a complication and should be avoided as it may delay healing. The base solution of TPN being dense in dextrose increases the risk for central line-associated bloodstream infection (CLABSI) because fungus and bacteria would be attracted to the dextrose. Air embolism, although rare, may occur if any IV product is not appropriately primed. Dehydration is a possible complication if hyperglycemia also occurs. If the glucose levels are high, this will trigger osmotic diuresis, leading to polyuria. This polyuria would cause dehydration. If the blood glucose remains well controlled, dehydration will not occur with TPN administration. Choice D is incorrect. Cardiac tamponade is not a complication of TPN administration. Tamponade occurs when there is bleeding or effusion into the pericardial cavity and a subsequent, abrupt increase in central venous pressure with a decrease in systemic blood pressure.

The nurse is providing health education on a client with dumping syndrome. Which teaching point about drinking fluids is accurate? A. The client should drink fluids immediately before meals B. The client must only drink fluids with meals C. The client must drink fluids before and during meals D. The client should drink fluids at least a half an hour after meals

Explanation Choices A, B, C, and E are correct. The base solution of TPN is dextrose 50%, and this concentrate will increase blood glucose levels. Hyperglycemia (blood glucose > 250 mg/dL) is a complication and should be avoided as it may delay healing. The base solution of TPN being dense in dextrose increases the risk for central line-associated bloodstream infection (CLABSI) because fungus and bacteria would be attracted to the dextrose. Air embolism, although rare, may occur if any IV product is not appropriately primed. Dehydration is a possible complication if hyperglycemia also occurs. If the glucose levels are high, this will trigger osmotic diuresis, leading to polyuria. This polyuria would cause dehydration. If the blood glucose remains well controlled, dehydration will not occur with TPN administration. Choice D is incorrect. Cardiac tamponade is not a complication of TPN administration. Tamponade occurs when there is bleeding or effusion into the pericardial cavity and a subsequent, abrupt increase in central venous pressure with a decrease in systemic blood pressure. Learning Objective Recognize the critical complications of TPN administration.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for peptic ulcer disease (PUD)? Select all that apply. A. Prolonged ibuprofen use B. Tobacco use C. Irritable bowel syndrome D. H. pylori E. Alcohol consumption

Explanation Choices A, B, D, and E are correct. These products are gastric irritants, and overexposure to these substances may cause PUD. Prolonged NSAID use (such as ibuprofen) is commonly implicated in the causation of PUD because of their ability to inhibit COX-1 in the gastrointestinal tract. H. pylori is a gram-negative bacteria that may be acquired by an individual consuming contaminated food or water. Alcohol and tobacco usage causes more gastric acid to be discharged. When used together, the risk for PUD is substantially increased. Choice C is incorrect. IBS is a functional GI disorder that causes spasms of the large bowel. This disorder is not implicated in causing PUD. Additional Info Three ulcers make up PUD and include duodenal ulcers, gastric ulcers, and stress ulcers. Many ulcers are caused by H. pylori infection. Gastric ulcers usually develop in the antrum of the stomach near acid-secreting mucosa. Duodenal ulcers occur more often than other types. Most duodenal ulcers are present in the upper portion of the duodenum. Stress ulcers are acute gastric mucosal lesions occurring after an acute medical crisis or trauma. Treatment for PUD includes PPIs, H2 blockers, and antibiotics if the cause is H. pylori.

The nurse prepares to administer a cycled tube feeding to a client through the nasogastric tube. Before initiating the feed, which actions would be appropriate for the nurse to take? Select all that apply. A. Flush the nasogastric tube with sterile water or potable tap water. B. Verify placement of the nasogastric tube. C. Elevate the head of the bed. D. Ask the client to remain in bed during the tube feeding.

Explanation Choices A, B, and C are correct. A is correct. Before beginning a cycled tube feeding, the nurse should flush the nasogastric tube with sterile water. If the patient is not immunocompromised or critically ill, potable tap water is also appropriate for flushing the feeding tube. Sterile saline can be used in patients with hyponatremia. Flushing the enteral tube before feeding helps to confirm that the tube is patent and ensures that the formula freely flows into the client's gastrointestinal tract during the feeding. B is correct. It is essential to always verify the placement of the nasogastric tube before putting anything in it. If the tube has moved and the tip of it is no longer in the stomach, the feeding could be aspirated, causing serious problems such as pneumonia. The gold standard to verify tube placement is visualization on an x-ray. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nursing staff can check that the tube has not moved and remains in the stomach prior to each feeding. C is correct. It is appropriate to elevate the head of the bed before any tube feeding. This allows gravity to help the tube feeding flow into the stomach and prevent reflux. For clients receiving a bolus feeding, a high-Fowler's position is preferred, and for clients receiving a cycled or continuous feeding, a semi-Fowler's position is preferred. Choice D is incorrect. The nurse doesn't need to instruct the client to remain in bed for the duration of their tube feeding. However, some clients may prefer to stay in bed, or they may like to get up to the chair, sit up, get up to ambulate to the restroom, etc. Last Updated - 15, Nov 2021

The nurse in the ICU is caring for a patient receiving total parenteral nutrition (TPN). Essential nursing diagnoses on the care plan for this patient include: Select all that apply. A. Risk for fluid volume imbalance B. Risk for infection C. Risk for hyperglycemia D. Risk for gastrointestinal tract dysfunction

Explanation Choices A, B, and C are correct. This patient is at risk for fluid volume imbalance, infection, and hyperglycemia. These risks occur because of the high volume of glucose in most TPN solutions and because the nurse administers the solution through a central venous catheter. Any time the nurse delivers nutrition through an IV catheter, the patient is at risk for fluid volume imbalance. Choice D is incorrect. TPN does NOT predispose a patient to gastrointestinal tract dysfunction. However, in a case with a patient who has GI dysfunction, enteral nutrition through an NG or other tube might be contraindicated. NCSBN Client Need Topic: Pharmacological and Parenteral Therapies, Sub-topic: Total Parenteral Nutrition; Pharmacology; Gastrointestinal/Nutritional

A nurse on the surgical floor is caring for a patient who is three days post-splenectomy. During 0700 vital signs, the CNA obtains a 100.2-degree temperature but forgets to tell the nurse about this finding. At 1500, the nurse takes the patient's temperature, and it is 101.8 degrees. After documenting the findings, the nurse should do which of the following? Select all that apply. A. Administer amoxicillin per the standing order B. Call the physician immediately C. Palpate the patient's right upper quadrant D. Administer acetaminophen E. Place the patient in the Trendelenburg position

Explanation Choices A, B, and D are correct. After splenectomy, the patient is at high risk for developing OPSI (overwhelming post-splenectomy infection) and the nurse should recognize signs of an infection early on. Administering antibiotics and antipyretics for a fever is crucial to prevent the disease from worsening. The doctor should be called immediately because further treatment may be necessary. Choices C and E are incorrect. Palpating the patient's RUQ will not tell the nurse any vital information since the spleen would be palpated on the LUQ. The patient should not be placed in the Trendelenburg position because this will have no change in the patient's status. NCSBN Client Need Topic: Physiological Integrity, Sub-Topic: Reducing Risk, Care of the Surgical Patient Last Updated - 12, Nov 2021

The nurse is educating the client with urinary tract calculi regarding diet. Which of the following foods may the client have? Select all that apply. A. Broccoli B. Lettuce C. Cheese D. Apples Submit Answer

Explanation Choices A, B, and D are correct. The client may have broccoli, lettuce, and apples. Lettuce and apples are low in calcium and oxalate. Broccoli is high in calcium. However, it is low in oxalate and high in potassium. Being high in potassium, broccoli reduces calcium excretion in urine and reduces the formation of kidney stones. Therefore, this is the reason that it need not be held back in renal calculi. Kidney stones in the urinary tract are formed in several ways. Calcium can combine with chemicals, such as oxalate or phosphorous, in the urine. This can happen if these substances become so concentrated that they solidify. Kidney stones can also be caused by a buildup of uric acid related to the metabolism of protein. Most urinary tract calculi, especially calcium oxalate stones, can be prevented by following dietary recommendations. Generally, clients should avoid high calcium and high oxalate-containing foods. Clients should also be instructed to avoid stone-forming, high oxalate foods such as beets, chocolate, spinach, rhubarb, and tea. Most nuts are rich in oxalate and colas are rich in phosphate, both of which can contribute to kidney stones. Fluids, especially water, help to dilute the chemicals that form stones. Patients should be encouraged to drink at least eight glasses of water every day. Choice C is incorrect. Cheese has a high calcium content, which can increase the risk of developing urinary tract calculi and should, therefore, be avoided. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation

The nurse has provided medication instruction to a client who has been prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication one hour after meals." B. "I will remain upright for 30 minutes after taking this medicine." C. "This medication will help with my peptic ulcer disease." D. "I may get drowsy after I take this medication." E. "I may dissolve this medication in warm water."

Explanation Choices A, B, and D are correct. These statements are false and require further teaching. Sucralfate is a medication indicated in peptic ulcer disease. This medication should be taken one hour before meals as the medication will coat the ulcer allowing a client to eat meals without pain. The client is not required to be upright 30 minutes after taking this medication. This would be applicable instruction for a patient prescribed a bisphosphonate. Drowsiness is not a side-effect of sucralfate. This would be a common side-effect associated with histamine blockers such as famotidine. Choices C and E are incorrect. Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. The pills are rather large and may be dissolved in water to improve the client's ability to swallow. Additional Info Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. This medication should be taken one hour before meals and at bedtime. This medication allows the client to eat their meal without the pain of the ulcer. Constipation is the most common side-effect associated with this medication.

The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply. A. Leukocytosis B. Melena C. Fever D. Nausea and Vomiting E. Anorexia

Explanation Choices A, C, D, and E are correct. Manifestations associated with appendicitis include leukocytosis, fever, nausea and vomiting, and anorexia. Choice B is incorrect. Melena is black tarry stools that occur because of gastrointestinal bleeding. This is not a feature of appendicitis. Additional Info Appendicitis is an emergency that features pain in the right lower quadrant, nausea and vomiting, fever, leukocytosis, and anorexia. Appendicitis may be caused by obstruction, which will lead to inflammation and pressure. Nursing care for appendicitis includes - Maintaining nothing by mouth (NPO) status. Initiating an intravenous (IV) catheter. Administering prescribed antibiotics and IV fluids. Preparing the patient for surgery. The client should be monitored for perforation, which may be manifested by increased pain with coughing.

Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply. A. Draw up 30 mL of saline solution into the syringe. B. Unclamp the suction tubing near the connection site to instill solution. C. Place the tip of the syringe in the tube to gently insert saline solution. D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. E. After instilling the irrigant, hold the end of the NG tube over an irrigation tray. F. Observe for return of NG drainage into an available container.

Explanation Choices A, C, E, and F are correct. A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline (or the amount indicated on the order) into the syringe. C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution. E and F: After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container. Choices B and D are incorrect. B: The tubing should be clamped near the connection site to protect the patient from leakage of NG drainage. D: Place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube. The blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction. NCSBN Client Need Topic: Physiological integrity, Subtopic: Basic Care and Comfort; Nasoga

The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statement, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication with meals and with water." B. "I should not take this with any other medication or food." C. "The medication will coat my ulcer so I can eat without pain." D. "I will need frequent laboratory tests while taking this medication." E. "I may need to take magnesium supplements while on this medication."

Explanation Choices A, C, and D are correct. These statements are incorrect and require follow-up. Esomeprazole is a proton pump inhibitor (PPI) in treating esophageal erosion, GERD, and peptic ulcer disease. The medication should be taken one hour before meals and with an ample amount of water. The medication does not fortify an existing ulcer, like sucralfate. The client does not require frequent laboratory testing while on this medication. Choices B and E are incorrect. Correct teaching for a client receiving esomeprazole would include taking the medication independent of any other food or medicine as it will decrease its absorption. PPIs have the proclivity of causing hypomagnesemia, and thus, magnesium supplementation may be recommended by the PHCP. Additional Info PPIs are the gold standard in the treatment of GERD. The client should be instructed to take the medication first thing in the morning without any food or other medications. The long-term use of a PPI has been linked to osteoporosis and hypomagnesemia. Therefore, it is reasonable to recommend weight-bearing exercises as well as magnesium and calcium supplements approved by the primary healthcare provider (PHCP).

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer? Select all that apply. A. Ulcerative colitis B. Body Mass Index (BMI) = 21 C. Human Immunodeficiency Virus (HIV) infection D. Low-fiber diet E. Excessive alcohol consumption F. African-American ethnicity

Explanation Choices A, D, E, and F are correct. Risk factors for colorectal cancer are divided into modifiable and non-modifiable types. Modifiable risk factors are usually behavioral factors that can increase a person's risk of cancer. In theory, these risk factors can be modified with interventions. Non-modifiable risk factors are those that can not be changed. Awareness of the client's risk factors will help the health care provider prescribe personalized lifestyle and cancer screening recommendations. The gold standard of colorectal cancer prevention is a colonoscopy that should begin as early as age 45 (USPTF new guidelines, 2021). (Choice A) Inflammatory bowel disease (especially ulcerative colitis) is a non-modifiable risk factor that may cause cellular damage and hasten the risk of colorectal cancer. (Choice D) A diet low in fiber is a modifiable risk factor for colon cancer. Encourage the client to increase fiber intake and decrease red meat. (Choice E) Excessive alcohol intake is a modifiable risk factor for colorectal cancer. (Choice F) African American ethnicity is a non-modifiable risk factor for colorectal cancer. Choice B is incorrect. A BMI of 21 is optimal and is not a risk factor. Obesity is a modifiable risk factor for colorectal cancer. Obesity is defined as a Body Mass Index (BMI) ≥ 30 kg/m2. Choice C is incorrect. HIV is a risk factor for many malignancies such as testicular cancer, but not colorectal cancers. Since rates of colorectal cancer are similar between people with and without HIV, existing screening guidelines are sufficient for people with HIV. Another virus called human papillomavirus (HPV) has been implicated in colorectal cancers. Learning Objective: Recognize that the risk factors for colorectal cancer include age, African American ethnicity, family history of colon cancer, certain genetic conditions, a diet low in fiber, a diet rich in red meat, obesity, smoking, and inflammatory bowel conditions (ulcerative colitis). NCSBN Client Need Topic: Health Promotion and Maintenance; Subtopic: Perform targeted assessments; GI Last Updated - 12, Feb 2022

The nurse is preparing morning medications for a client with a nasogastric tube connected to low-intermittent wall suction. Which actions does the nurse take to ensure proper administration of this client's medications? Select all that apply. A. Position the client in Trendelenburg position. B. Verify correct placement of the tube before medication administration. C. Turn off the suction during medication administration. D. Return the NG tube to low-intermittent wall suction after administering the medication.

Explanation Choices B and C are correct. B is correct. Before medication or food administration, it is crucial always to verify the correct placement of the nasogastric tube ( NGT). The gold standard to verify tube placement is visualization on an x-ray. The American Association of Critical-Care Nurses (AACN) guidelines recommend confirming the position of NGTs by X-ray. However, given the risks of radiation exposure with X-rays and delayed feeding, alternative options are often used to verify the tube placement before feeding or giving medications to the client. The most commonly used first-line verification method is measuring the pH of the NG tube aspirate to make sure it falls in line with that of gastric contents. Most guidelines recommend that the pH of an NGT aspirate should be ≤5.5 (acidic) to confirm proper placement. An alkaline pH ( >7.0) often indicates a lung aspirate rather than gastric. A false-negative pH reading greater than 5.5 may be seen with the use of antacids and proton pump inhibitors. If the pH is greater than 5.5, an X-ray must be performed as a second-line test. After the placement has been initially verified, the nurse may mark where the tube is located at the nare of the client so that the nurse can assess that the tube has not moved and remains in the stomach before each feed. C is correct. It is appropriate to turn off the suction during medication administration. If the client remained on low-intermittent wall suction, the medication would be evacuated from the stomach via suction before it could be absorbed. The nurse should stop the suction and clamp the nasogastric tube for 30 minutes after administering the medications to allow them to absorb fully. Choice A is incorrect. It would be highly inappropriate to place a client in the Trendelenburg position before administering medications through a nasogastric tube. To prevent aspiration, the nurse should sit the patient up as much as tolerated, raising the head of the bed at least 30 degrees. This will allow gravity to help the medication flow into the stomach for absorption. Choice D is incorrect. Returning the NG tube to low-intermittent wall suction is not appropriate after administering the medication. This process would prevent the medications from wholly absorbing. The nurse should clamp the nasogastric tube for 30 minutes after medication administration to allow for medication absorption. Then the nurse may return the NG tube to low-intermittent wall suction.

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply. A. Furosemide B. Neomycin C. Naproxen D. Lactulose E. Diazepam

Explanation Choices B and D are correct. Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Choices A, C, and E are incorrect. Potassium-wasting diuretics such as furosemide should be avoided because it contributes to hypokalemia. Hypokalemia contributes to the production of ammonia. Thus, a highly preferred diuretic in mitigating ascites is potassium-sparing diuretic spironolactone. NSAIDs should be avoided because of their nephrotoxic and anticoagulation effects. Low doses of acetaminophen may be approved for mild to moderate pain. Benzodiazepines, such as diazepam, should be avoided for a client with hepatic encephalopathy. These medications can worsen a client's sensorium, putting the client at high risk for falls and injury. Additional Info Treatment options for hepatic encephalopathy would include prescribed potassium-sparing diuretics, lactulose, and antibiotics such as neomycin or rifaximin. Nursing care aims to assist the client in achieving and maintaining treatment adherence and the avoidance of medication such as NSAIDs and benzodiazepines that could worsen the encephalopathy. Last Updated - 28, Apr 2022

The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply. The newly hired nurse A. empties the pouch when it is one-third to one-half full. B. washes the surrounding skin with moisturizing soap. C. indicates that the reddish appearance of the stoma as normal. D. applies sterile gloves prior to changing the device. E. applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer. Submit Answer

Explanation Choices B, D, and E are correct. These actions are incorrect and require follow-up. A mild soap should be used when cleaning peristomal skin. If moisturizing soap is used, the moisturizers will inhibit a good seal to the skin by the wafer. Sterile gloves are not necessary when performing ostomy care. Using sterile gloves would incur costs and be a waste of organizational resources. Finally, isopropyl alcohol is drying to the skin and irritates it. This should not be used on peristomal skin. Choices A and C are incorrect. These actions are correct and do not require follow-up. The pouch should be emptied when it is one-third to one-half full. A reddish or pink moist stoma indicates adequate perfusion and is normal. Stomas that appear purple, dry, and black require follow-up with the physician because this is unexpected. Additional Info ✓ After a colostomy is established, it usually begins to produce stool within two to three days following surgery. ✓ The stoma should be reddish-pink and moist. ✓ The appliance (device) should be changed every three to seven days. ✓ The pouch should be emptied when it is one-third to one-half full. ✓ Skin care is essential, and the peristomal skin should be inspected frequently for breakdown. ✓ The surrounding skin should be cleaned with mild soap and water. Then, it should be patted dry. ✓ Stoma powder/paste may be used on clean skin to promote adherence with the wafer. ✓ Assess the client's psychosocial readiness for performing self-care. Last Updated - 05, Feb 2023

The nurse assists a client with diverticulosis select appropriate foods on a menu. Which food choice, if made by the client, would require further teaching? Select all that apply. A. Bran cereal B. Fresh peaches C. White toast D. Scrambled eggs E. Cabbage soup

Explanation Choices C and D are correct. Diverticulosis requires the client to adhere to a high-fiber diet. White toast and eggs are low in fiber and would require follow-up by the nurse. Wheat bread would be a better choice. Choices A, B, and E are incorrect. These food items are rich in fiber and do not require follow-up. Bran cereal, fresh fruit, and cabbage are appropriate choices. Additional Info Diverticulosis is a condition in which the client develops small herniations in the large bowel. A common cause of this condition is a low-fiber diet. The client is instructed to increase their fiber and water intake as these measures are key in promoting bowel motility. If the client should develop diverticulitis, the prescribed diet is NPO (nothing by mouth) status and slowly advanced to clear liquids.

Your client asks you which foods he can eat so that he gets the recommended daily allowance of vitamins. Select the vitamins that are accurately paired with major food sources. Select all that apply. A. Niacin (B3): Corn and other grains B. Riboflavin (B2): Citrus and milk C. Folate (B9): Liver and legumes D. Vitamin K: Liver and leafy green vegetables E. Vitamin D: Fish and fortified milk F. Pantothenic acid (B5): Grains and legumes

Explanation Choices C, D, E, and F are correct. Folate is found in liver, legumes, and leafy green vegetables. Vitamin K is found in leafy green vegetables and liver. Vitamin D is found in fortified milk and fish. Pantothenic acid (B5) is found in whole grains, avocado, beans, legumes (lentils), lean chicken, beef, pork, and broccoli. Pantothenic acid is ubiquitous and hence, a deficiency is very rare except in severe malnutrition. Choice A is incorrect. Niacin (B3) is found primarily in meats, liver, fish, legumes, peanuts, coffee, and tea. It is deficient in corn and refined grains. Choice B is incorrect. Riboflavin (B2) is found in leafy green vegetables and milk, but not in citrus. Last Updated - 14, Oct 2021

The nurse is caring for an 82-year-old client with cancer. Due to the chemotherapy treatments, the client is unable to take in enough calories to meet their nutritional requirements. The MD orders an NG tube to be inserted. Place the following actions in the correct order for the nurse to correctly insert the NG tube: Secure the NG tube at the pre-measured mark. Measure the length of the NG tube from the nose to the earlobe to the xiphoid process. Encourage the patient to swallow a few sips of water and advance the NG tube past the oropharynx. Lubricate the tip of the NG tube. Insert the NG tube in the nare pushing it gently back and down toward the ear. Submit Answer

Explanation Correct ordered sequence: C, D, A, E, B Before beginning the procedure the nurse should verify the order, gather her supplies, perform hand hygiene, identify the patient using 2 patient identifiers, and explain the procedure to the patient. Once she is ready to begin, first measure the length of the NG tube from the nose to the earlobe to the xiphoid process. Second, lubricate the tip of the NG tube. Third, insert the NG tube in the nare pushing it gently back and down toward the ear. Fourth, encourage the patient to swallow a few sips of water as you advance the NG tube past the oropharynx. Lastly, secure the NG tube at the pre-measured mark. After the nurse is done she should verify the placement of the NG tube per the institution's protocol. The gold standard for nasogastric tube verification is visualization with an x-ray. NCSBN Client Need: Topic: Reduction of Risk Potential; Subtopic: Potential for Complications of Diagnostic Tests/Treatments/Procedures; Adult Health - Gastrointestinal Last Updated - 17, Sep 2020