Gastrointestinal Patients NCLEX (3 of 3)

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse interprets that the client is using which coping mechanism? 1. Distancing 2. Self-control 3. Problem solving 4. Accepting responsibility

1 ~ Distancing is an unwillingness or inability to discuss events. Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and verbalizing what will be done. Accepting responsibility places the responsibility for a situation on oneself.

A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1. Rice 2. Whole milk 3. Broiled fish 4. Baked chicken

2 ~ Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to the option of whole milk. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1. Ibuprofen 2. Ranitidine 3. Acetaminophen 4. Acetylsalicylic acid

3 ~ Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in the remaining options.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1. Evaluating for asterixis 2. Inspecting for petechiae 3. Palpating for peripheral edema 4. Evaluating for decreased level of consciousness

3 ~ Albumin is responsible for maintaining the osmolality of the blood. When there is a low albumin level, there is decreased osmotic pressure, which in turn can lead to peripheral edema. The remaining options are incorrect and are not associated with a low albumin level.

The nurse plans care for a client postoperatively following creation of a colostomy. Which potential client problem should the nurse include in the plan of care? 1. Fear 2. Anxiety 3. Sexual dysfunction 4. Upset about appearance

4 ~ Being upset about appearance relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support the remaining problems.

The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement? 1. "It will help to provide me with nourishment." 2. "It will help to relieve the congestion from excess mucus." 3. "It is used to remove gastric contents for laboratory testing." 4. "It will help to remove gas and fluids from my stomach and intestine."

4 ~ Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1 ~ An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1. Fatigue 2. Pale urine 3. Weight gain 4. Spider angiomas

1 ~ Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? 1. NPO (nothing by mouth) status 2. Ambulation at least 4 times daily 3. Cholinergic medications to reduce pain 4. Coughing and deep breathing every 2 hours

1 ~ During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms, and increased intra-abdominal pressure (coughing and deep breathing) may precipitate an attack. Ambulation and cholinergics will increase peristalsis.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client? 1. A low-fat diet 2. A low-fiber diet 3. A high-protein diet 4. A high-carbohydrate diet

2 ~ A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1. Eating helps to decrease the pain. 2. The pain usually increases after vomiting. 3. The pain is mostly around the umbilicus and comes and goes. 4. The pain increases when the client sits up and bends forward.

2 ~ Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? (SATA) 1. Antidiarrheal 2. Antimicrobial 3. Corticosteroid 4. Aminosalicylate 5. Biological therapy 6. Immunosuppressant

2, 3, 4, 5, 6 ~ Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? (SATA) 1. Insulin 2. Morphine 3. Dicyclomine 4. Pancrelipase 5. Pantoprazole 6. Acetazolamide

2, 3, 5, 6 ~ Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1. Digoxin 2. Furosemide 3. Indomethacin 4. Propranolol hydrochloride

3 ~ Indomethacin is a nonsteroidal antiinflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1. Full liquid diet 2. Morphine sulfate for pain 3. Nasogastric tube insertion 4. An anticholinergic medication

1 ~ The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1. Fat 2. Protein 3. Carbohydrate 4. Water-soluble vitamins

1 ~ The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results? 1. Elevated serum lipase level 2. Elevated serum bilirubin level 3. Decreased serum trypsin level 4. Decreased serum amylase level

1 ~ The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1. Pork 2. Milk 3. Chicken 4. Broccoli

1 ~ Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? (SATA) 1. Eat yogurt. 2. Take loperamide to treat diarrhea. 3. Use stress management techniques. 4. Avoid foods such as cabbage and broccoli. 5. Decrease fiber intake to less than 15 g/day.

1, 2, 3, 4 ~ IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day.

The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? (SATA) 1. Pull the tube back slightly. 2. Instruct the client to breathe slowly. 3. Assist the client to take sips of water. 4. Continue to slowly advance the tube to the desired distance. 5. Check the back of the pharynx using a tongue blade and flashlight.

1, 2, 3, 5 ~ As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.

The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? (SATA) 1. Do not drink fluids with meals. 2. Avoid foods high in carbohydrates. 3. Take an extended-release multivitamin daily. 4. Maintain a clear liquid diet for about 6 weeks. 5. Eat 6 small meals a day that are high in protein.

1, 2, 5 ~ A Roux-en-Y gastric bypass is a combination of restrictive and malabsorptive surgery in which the size of the stomach is made much smaller and a large part of the small intestine (which absorbs food) is bypassed. Because the stomach is so small, clients are instructed to not drink fluids with meals because providers do not want them to fill up on less nutritional liquids before having food; to avoid foods high in carbohydrates because they are not as nutritional and tend to promote diarrhea and dumping syndrome; and to eat frequent, small meals that are high in protein. An extended-release vitamin will not be absorbed by the client since much of the small intestine is bypassed and food moves through quickly, and 6 weeks is too long a period to be on clear liquids. The typical bariatric surgery client is only on clear liquids for a few days and should then be on a high-protein diet.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1. "I will obtain adequate rest." 2. "I will take acetaminophen if I get a headache." 3. "I should monitor my weight on a regular basis." 4. "I need to include sufficient amounts of carbohydrates in my diet."

2 ~ Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include? 1. Alcohol should be consumed in moderation. 2. Avoid caffeine because it may aggravate symptoms. 3. Diet should be high in carbohydrates, fats, and proteins. 4. Frothy, fatty stools indicate that enzyme replacement is working.

2 ~ Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy, fatty stools indicate that the replacement enzyme dose needs to be increased.

A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? 1. On arising 2. After meals 3. On an empty stomach 4. 30 minutes before meals

2 ~ Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.

A client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse should teach the client to include which food in the diet to reduce odor? 1. Eggs 2. Yogurt 3. Broccoli 4. Cucumbers

2 ~ The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods.

The nurse is teaching the post-gastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? 1. "I need to lie down after eating." 2. "I need to drink liquids with meals." 3. "I need to avoid concentrated sweets." 4. "I need to eat small meals 6 times daily."

2 ~ The client with dumping syndrome should avoid drinking liquids with meals. The client should be placed on a high-protein, moderate-fat, high-calorie diet and should lie down after eating. The client should avoid concentrated sweets, and frequent small meals are encouraged.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Drawing the legs to the chest

2 ~ The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? (SATA) 1. Select foods high in protein content. 2. Consume multiple small meals throughout the day. 3. Select foods low in carbohydrates to prevent nausea. 4. Allow the client to select foods that are most appealing. 5. Eliminate fatty foods from the meal trays until nausea subsides. 6. Eat a nutritious dinner because it is typically the best tolerated meal of the day.

2, 4, 5 ~ Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? 1. Ibuprofen 2. Indomethacin 3. Acetaminophen 4. Naproxen sodium

3 ~ Analgesics, such as acetaminophen, are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal antiinflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they should be avoided in clients with gastritis.

A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration? 1. Drink 8 ounces of water between taking each medication. 2. Administer the cimetidine and magnesium hydroxide at the same time twice daily. 3. Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. 4. Collaborate with the health care provider (HCP), as the client should not be receiving both medications.

3 ~ Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.

The nurse is caring for a client who is receiving bolus feedings via a nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat for sleep. The nurse understands that which is the appropriate position for this client at this time? 1. Head of bed flat, with the client supine for 60 minutes 2. Head of bed flat, with the client in the supine position for at least 30 minutes 3. Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes 4. Head of bed in a semi Fowler's position, with the client in the left lateral position for 60 minutes

3 ~ Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for 60 minutes after a bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying and thus prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding.

The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? 1. Enteral feedings 2. Fluid restrictions 3. Oral corticosteroids 4. Activity restrictions

3 ~ Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.

The nurse is caring for a client postoperatively after creation of a colostomy. What is an appropriate potential client problem? 1. Fear 2. Sexual dysfunction 3. Disturbed body image 4. Imbalanced nutrition: more than body requirements

3 ~ Disturbed body image for a client who is postoperative after creation of a colostomy relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction or fear. Imbalanced nutrition: less (not more) than body requirements is the more likely client problem.

The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications are not a part of the treatment plan because of its irritating effects on the lining of the gastrointestinal tract? 1. Nizatidine 2. Sucralfate 3. Ibuprofen 4. Omeprazole

3 ~ Ibuprofen is a nonsteroidal antiinflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract.

The nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primary characteristics of the preicteric phase? 1. Pruritus 2. Right upper quadrant pain 3. Fatigue, anorexia, and nausea 4. Jaundice, dark-colored urine, and clay-colored stools

3 ~ In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? 1. Increase potassium in the diet. 2. Include rice and bananas in the diet. 3. Increase fluid and dietary fiber intake. 4. Increase the intake of sugar-free products.

3 ~ Increase of fluid intake and dietary fiber will help change the consistency of the stool, making it easier to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not assist in alleviating constipation.

The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. White blood cell (WBC) count of 4000 mm3 (4 × 109/L) 2. WBC count of 8000 mm3 (8 × 109/L) 3. WBC count of 18,000 mm3 (18 × 109/L) 4. WBC count of 26,000 mm3 (26 × 109/L)

3 ~ Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).

The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? 1. A pale color 2. A purple color 3. A brick-red color 4. A large amount of red drainage

3 ~ Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? 1. Hypotension 2. Bloody diarrhea 3. Rebound tenderness 4. A hemoglobin level of 12 mg/dL (120 mmol/L)

3 ~ Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the HCP.

The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching? 1. "It is normal to feel gassy or bloated after the procedure." 2. "The abdominal muscles may be tender from the procedure." 3. "It is all right to drive once I've been home for an hour or so." 4. "Intake should be light at first and then progress to regular intake."

3 ~ The client should not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client should resume intake slowly and progress as tolerated.

A client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure? 1. Assessing pulses 2. Monitoring urine output 3. Monitoring for rectal bleeding 4. Assessing for the presence of the gag reflex

4 ~ Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? 1. "The pain doesn't usually come right after I eat." 2. "The pain gets so bad that it wakes me up at night." 3. "The pain that I get is located on the right side of my chest." 4. "My pain comes shortly after I eat, maybe a half-hour or so later."

4 ~ Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period? 1. "When I can tolerate food without vomiting." 2. "When my gastrointestinal system is healed enough." 3. "When my health care provider says the tube can come out." 4. "When my bowels begin to function again, and I begin to pass gas."

4 ~ NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the health care provider (HCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? 1. "I know I can massage my abdomen." 2. "I will continue using antispasmodic medication." 3. "One of the best things I can do is use relaxation techniques." 4. "The best position for me is to lie supine with my legs straight."

4 ~ Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.

The nurse is caring for a client with pernicious anemia. Which prescription by the health care provider (HCP) should the nurse anticipate? 1. Iron 2. Folic acid 3. Vitamin B6 4. Vitamin B12

4 ~ Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.

A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals? 1. Looking at the ostomy site 2. Reading the ostomy product literature 3. Watching the nurse empty the ostomy bag 4.Practicing proper cutting of the ostomy appliance

4 ~ The client is expected to have body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest degree of acceptance when he or she participates in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care.

A client is resuming a diet after hemigastrectomy, and the nurse provides dietary instructions. Which statement by the client indicates a need for further teaching? 1. "I plan to lie down after eating." 2. "I know to avoid sweets in my diet." 3. "I will eat several small meals per day." 4. "I will drink plenty of liquids with meals."

4 ~ The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets. Lying down for a short period of time after eating is beneficial.

The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma? 1. Massage the area below the stoma. 2. Take in high-fiber foods such as nuts. 3. Limit fluid intake to prevent diarrhea. 4. Cleanse the peristomal skin meticulously.

4 ~ The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? (SATA) 1. Monitor serum potassium levels. 2. Weigh client daily, and monitor trends. 3. Monitor for symptoms of fluid retention. 4. Provide the client with a soft toothbrush. 5. Instruct the client to use an electric razor. 6. Monitor all secretions for frank or occult blood.

4, 5, 6 ~ Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1. Chili 2. Bagel 3. Lentil soup 4. Watermelon

1 ~ The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet? 1. Protein 2. Calories 3. Minerals 4. Carbohydrates

1 ~ Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? 1. Encourage the client to ambulate. 2. Position the client on the left side. 3. Frequently irrigate the nasogastric tube (NG) with 30 mL saline. 4. Discourage the use of the patient-controlled analgesia (PCA) machine.

1 ~ Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications.

A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action should be the priority for this client? 1. Assessment of vital signs 2. Complete abdominal examination 3. Thorough investigation of precipitating events 4. Insertion of a nasogastric tube and Hematest of emesis

1 ~ The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority.

The nurse is preparing to administer an intermittent enteral feeding though a nasogastric (NG) tube. Which priority assessment should the nurse perform? 1. Observe for digestion of formula. 2. Assess fluid and electrolyte status. 3. Evaluate absorption of the last feeding. 4. Evaluate percussion tone of the stomach.

3 ~ All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.

A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? 1. Discontinue the enema. 2. Reassure the client, and continue the flow. 3. Raise the enema bag so that the solution can be completed quickly. 4. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

4 ~ Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1. Difficulty with sleeping 2. Risk for skin breakdown 3. Difficulty with breathing 4. Excessive body fluid volume

4 ~ The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor? 1. Alcohol intake 2. Duodenal ulcer 3. Crohn's disease 4. Diabetes mellitus

1 ~ Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not specifically associated with pancreatitis.