GI Ch. 51, 52, 55
A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer? -. A 72-year-old who eats fast food frequently.
A NS: DColon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.
A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? - Serum potassium of 2.6 mEq/L (2.6 mmol/L)
ANS: A Fistulas place the patient with Crohn disease at risk for hypokalemia which can lead to serious dysrhythmias. This potassium level is low and would cause the nurse to intervene. The white blood cell count is normal. The other two findings are abnormal and also warrant intervention, but the potassium level takes priority.
A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? - Sepsis
ANS: C The client who has a strangulated inguinal hernia would likely develop bowel necrosis which can lead to sepsis. The nurse would observe for early signs and symptoms of sepsis such as fever, tachypnea, and tachycardia. If the client's condition is not promptly managed, bowel perforation, septic shock, and death can result.
The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? -Drink plenty of fluids to prevent dehydration.
ANS: A The client should drink plenty of fluids to prevent dehydration. Milk products may not be tolerated. Caffeinated beverages increase intestinal motility and should be avoided.
The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? - Check the skin around the tube insertion site.
ANS: A The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated.
The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider? -Pale and bluish stoma
ANS: A The nurse would assess the stoma for color and contact the primary health care provider if the stoma is pale, bluish, or dark because these changes indicate possible lack of perfusion. The nurse would expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.
A nurse cares for a client who has a new colostomy. Which action would the nurse take? - Empty the pouch frequently to remove excess gas collection.
ANS: A The nurse would empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy barriers would be used to secure and seal the ostomy appliance; surgical tape would not be used.
A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How would the nurse respond? -The stool will always be liquid with this type of colostomy."
ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet or with the passage of time.
The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? -Ask the client if the weight loss was intentional.
ANS: A This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted.
The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) - Alopecia - Stomatitis - Muscle wasting - Peripheral edema -Anemia - Dry, scaly skin
ANS: A, B, C, D, E, F All of these body changes occur due to nutrient deficiencies associated with low protein, zinc, Vitamin A, and complex B vitamins.
The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) - Apply ice to the surgical area for the first 24 hours after surgery. - Encourage ambulation with assistance within the first few hours after surgery. - Encourage deep breathing after surgery but teach the client to avoid coughing. - Assess vital signs frequently for the first few hours after surgery. - Teach the client to rest for several days after surgery when at home. -Teach the client not to lift more than 10 lb (4.5 kg) until allowed by the surgeon.
ANS: A, B, C, D, E, F All of these nursing actions are appropriate for the client having MIS for inguinal hernia repair.
A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) - Does your gym provide yoga classes? - When should you contact your provider? - What do you plan to eat for dinner? -How many bathrooms are in your home?
ANS: A, B, C, E A home assessment for a client who has a chronic inflammatory bowel disease would include identifying adequacy and availability of bathroom facilities, opportunities for rest and relaxation, and the client's knowledge of dietary therapy, and when to contact the primary health care provider. The client does not need to perform daily weights.
The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) - Contour of the abdomen when standing - Location of the client's belt line - Contour of the abdomen when lying - Contour of the abdomen when sitting
ANS: A, B, C, E Before marking the placement for the ostomy, the nurse would consider the contour of the abdomen in lying, sitting, and standing positions, the location of the belt line and possible location in the rectus muscle. The location of abdominal muscles is not considered.
When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) -Allow uninterrupted time for eating. - Assess dentures (if worn) for appropriate fit. - Ensure that the client has glasses on or contacts in when eating. - Serve high-calorie, high-protein snacks one to two times a day.
ANS: A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated.
After teaching a patient who has a permanent ileostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) - Corn - String beans - Wheat rice
ANS: A, B, D Clients with an ileostomy should be cautious of high-fiber and high-cellulose foods including corn, string beans, and rice. Carrots and squash are low-fiber items.
The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) -Lower gastrointestinal bleeding—erosion of the bowel wall - Abscess formation—localized pockets of infection develop in the ulcerated bowel lining - Nonmechanical bowel obstruction—paralysis of colon resulting from colorectal cancer
ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.
The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) - Need to have drug administered by a primary health care provider. -Need to avoid crowds and individuals who have infection. - Awareness of a rare but potentially fatal drug complication. - Need to report any signs and symptoms of infection immediately.
ANS: A, B, D, E All of these choices are correct except that the drug is given intravenously. Therefore, there is no need to teach the client to report injection reactions because the client does not self-administer the medication subcutaneously. Natalizumab can cause progressive multifocal leukoencephalopathy (PML), but it is a very rare disorder causing cognitive, sensory, and/or motor changes.
The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) - Nausea and vomiting - Abdominal pain - Bradycardia - Decreased urinary output - Fever
ANS: A, C, D, E, F Peritonitis is an acute inflammatory disorder. Therefore, the client would likely have all of these signs and symptoms but would have tachycardia rather than bradycardia due to dehydration from fever.
The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) - Assist the client into a side-lying position.. - Apply warm compresses three to four times a day. - Place an absorbent dressing over the wound.
ANS: A, C, E The nurse would place an absorbent pad over the wound and apply warm compresses to the wound area. The nurse would also instruct the male client to wear jockey-type shorts for support rather than boxers, assume a side-lying position in bed, avoid sitting for long periods, and use foam pads or soft pillows whenever in a sitting position. The patient should avoid the use of air rings or rubber donut devices.
The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) - Assess for proper placement of the tube every 4 hours or per agency policy. - Disconnect suction when auscultating bowel peristalsis. - Monitor the client's skin around the tube site for irritation.
ANS: A, D, E The nurse would frequently assess for NGT placement, patency, and output (drainage) every 4 hours or per agency policy. The nurse would also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse would disconnect suction. NGT irrigation may or may not be prescribed. If it is prescribed, hourly irrigation is not appropriate.
A client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? -You should be able to have better bowel continence after healing occurs
ANS: B A RCA-IPAA can improve bowel continence although leakage may still occur for some clients. The procedure is a 2-step process performed under general anesthesia using a laparoscope which does not require an abdominal incision or permanent ileostomy.
The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? -Alvimopan
ANS: B Alvimopan is the appropriate drug to promote peristalsis for clients who have a paralytic ileus. The other drugs do not affect intestinal activity.
A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide? -Report any suicidal thoughts to your primary health care provider
ANS: B Lorcaserin can cause suicidal thoughts which needs to be reported to the client's primary health care provider. This drug can also cause dry mouth but not decreased sweating. Loose stools are most common with orlistat. Increasing fiber and water would help to prevent constipation, not diarrhea.
A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? Beginning venous thromboembolism prophylaxis
ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first.
The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? -. Consuming raw seafood
ANS: D Raw seafood is often contaminated and unless cooked can would most likely cause gastroenteritis. Any of the other food can also become contaminated if not stored properly or contaminated by workers/cooks who contaminate these foods.
The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action? -Skin protection
ANS: B Protecting the client's skin is the priority action for a patient who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn disease also includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.
A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How would the nurse respond? -Tell me more about your concerns
ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse would encourage the client to discuss concerns by restating them in an open-ended manner. The nurse would not minimize the client's concerns or provide false reassurance.
The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) -Stoma becomes dark and dull. - Skin around the stoma becomes excoriated. - Skin around stoma becomes protruded. - Stoma becomes retracted into the abdomen.
ANS: B, C, D, E A colostomy placed in the descending colon would be expect to have a paste-like stool consistency. However, if the stoma becomes retracted or discolored, the client should report those changes to the primary health care provider. Skin around the stoma that becomes protruded would suggest the formation of a peristomal hernia, and skin excoriation needs appropriate management. Therefore, both of those skin changes would need to be reported to the primary health care provider.
The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) - Rectal bleeding - Anemia -Change in stool shape - Abdominal discomfort
ANS: B, C, D, F The client who has CRC usually experiences unintentional weight loss and rectal bleeding, either gross or occult. As a result of bleeding, the client has anemia and fatigue. Electrolyte imbalances are not common, but the client may note that the shape or consistency of stool has changed.
The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? - The client is obese.
ANS: C A BMI of over 30 indicates that the client is obese.
A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? - Ensure an adequate airway.
ANS: C All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management.
A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first? - Heart rate and rhythm
ANS: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client would have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment but are lower priority for this patient than heart rate and rhythm.
After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? -I will take a laxative nightly at bedtime to avoid becoming constipated."
ANS: C Laxatives are not recommended for patients with diverticulitis because they can increase pressure in the bowel, causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for lifting prevents abdominal straining.
A nurse cares for a client with colorectal cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How would the nurse respond? -I will make a referral to the United Ostomy Associations of America."
ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including ostomates (specially trained visitors who also have ostomies). The nurse would not suggest that the client speak with a personal contact of the nurse. Although the ostomy nurse is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse would not brush aside the client's request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.
A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? - Take the client's vital signs.
ANS: C The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension.
A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation would the nurse teach the client? -Add vegetables such as broccoli and cauliflower to your diet."
ANS: C The client would be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.
The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? -High-pitched, rushing bowel sounds in the right lower quadrant
ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn disease. A positive Murphy sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn disease. Nightly worsening of abdominal cramping is not consistent with Crohn disease.
A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? -Hold the feeding until the vomiting subsides.
ANS: C The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.
A nurse cares for a young client with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How would the nurse respond? -Let's talk to the ostomy nurse about options for ostomy supplies and dress styles.
ANS: C The ostomy nurse is a valuable resource for patients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.
A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) -Ensure that warm and cold items stay at appropriate temperatures. -Remove bedpans, soiled linens, and other unpleasant items. -Sit with the client, making the atmosphere more relaxed.
ANS: C, D, E The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse.
The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? - I'll cook all the meals for my family."
ANS: D All of these statements are correct except for that the client should not prepare meals for others to help prevent transmission of gastroenteritis.
After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching? - Baked fish with steamed carrots and a glass of apple juice
ANS: D Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup [240 mL] of bean soup) would be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.
A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? - Check tube placement before each feeding.
ANS: D For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority.
The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed? - Semi-Fowler
ANS: D Having the client in a semi-sitting position helps to decrease the pressure caused by abdominal distention and promotes thoracic expansion to facilitate breathing.
The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? - Request an x-ray before starting the feeding.
ANS: D The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located.
The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement by the client indicates a need for further teaching? -I will probably be in the hospital for 3 to 4 days after surgery."
All of these statements are correct about having minimally invasive laparoscopic surgery except that the hospital stay will likely be only 1 or 2 days.
The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? -Elevated leukocyte count
Appendicitis is an acute inflammatory disorder that frequently results in elevation of leukocytes (white blood cells). Serum electrolytes are not affected because the client does not usually have diarrhea. Thrombocyte (platelet) count is unrelated to this GI disorder.
A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) - Determine if any of the medications come in liquid form. - Flush the tube before and after administering medications. - Try to flush the tube with 30 mL of water and gentle pressure.
If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula.
The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? - Decreasing fluid intake
The major cause of hemorrhoid formation is constipation. Therefore, the nurse teaches the client ways to prevent constipation, which include increasing dietary fiber, increasing exercise and fluid intake, and avoiding straining when have a stool.
A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) - Administer pain medications as prescribed. - Palpate the abdomen for distention. - Assess for sudden changes in mental status. - Evaluate stools for occult blood
When caring for an older adult who has diverticulitis, the nurse would administer analgesics as prescribed, palpate the abdomen for distention and tenderness, assess for confusion and sudden changes in mental status, and check stools for occult or frank bleeding. A low-fiber/residue diet would be provided when symptoms are present and a high-fiber diet when inflammation resolves.
A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? - Client with a cholesterol of 142 mg/dL (3.7 mmol/L)
A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.
A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How would the nurse respond? -Let's talk to the ostomy nurse to help you and your husband work through this."
ANS: A The nurse would collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse would not minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.
The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.) -Wash your hands after any contact with animals." -Use separate cutting boards for meat and vegetables."
ANS: A, D Washing hands after contact with animals and using separate cutting boards for meat and other foods will help prevent E. coli infection. The other statements are not related to preventing E. coli infection.
The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug? -Do you have any allergy to sulfa drugs?"
ANS: B Sulfasalazine is a sulfa drug given for clients who have ulcerative colitis. However, it should not be given to those who have an allergy to sulfa and sulfa drugs to prevent a hypersensitivity reaction.
A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the test? -You need to avoid red meat and NSAIDs for 48 hours before the test."
ANS: B The FOBT is a screening test that is sometimes used to assess for microscopic lower GI bleeding. To help prevent false positive results, the client needs to avoid red meat, Vitamin C, and NSAIDs. The test is not diagnostic nor does it determine a client's genetic risk for colorectal cancer.
A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) -Anorexia - Constipation -Abdominal pain
ANS: B, C, E Signs and symptoms of celiac disease include weight loss, anorexia, constipation, and abdominal pain. Anal fistulas are not associated with celiac disease.
The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? -. Aspiration pneumonia
ANS: C Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated.
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? - Assess the 24-hour intake and output. .
This client has clinical indicators of dehydration, so the nurse calculates the patient's 24-hour intake, output, and fluid balance. This information is then reported to the health care provider. The client's oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client's dehydration is most likely due to fluid shifts from the TPN, so increasing the infusion rate would make the problem worse, and is not done as an independent action for clients receiving TPN.
A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug? -Have you been experiencing any constipation?
Ischemic colitis is a life-threatening complication of alosetron. The nurse would assess the client for constipation because it places the client at risk for this complication. The other questions do not identify the risk for complications related to alosetron.
After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? -I will take this medication with my breakfast each morning.
ANS: B Adalimumab is an immune modulator that is given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so clients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.
A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take? - Recommend that the client have computed tomography.
ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or high-pitched bowel sounds, is indicative of bowel obstruction caused by the tumor. The nurse would contact the primary health care provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The nurse generalist is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.
The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? - Be sure to take this drug with food and water to help manage constipation
Lubiprostone is an oral laxative approved for women who have IBS with constipation (IBS-C). Water and food will also help to improve constipation. The drug is not used for clients who have diarrhea and does not affect the immune system. Although high-fiber foods are important for clients who have IBS, this client does not need fiber to help make stool more solid. Instead the fiber will help prevent constipation.
After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching? - Broiled chicken with brown rice, steamed broccoli, glass of apple juice
Patients with IBS are advised to eat a high-fiber diet. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. Clients should avoid alcohol, caffeine, and other gastric irritants.
The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect? -Severe, steady right lower quadrant pain
Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.
The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk? -Electrolyte imbalance
The client who has a small bowel obstruction is at the highest risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia due to profuse vomiting. Nausea, abdominal distention, and obstipation are also usually present, but these problems are not as life threatening as the imbalances in electrolytes.
A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.) -Which food types cause an exacerbation of symptoms? -Where is your pain or discomfort and what does it feel like?
The nurse would ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse would also assess the location, intensity, and quality of the patient's pain or discomfort. Clients who have IBS do not usually lose weight, have nausea and vomiting, or have stools that are black.
A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) -Use medicated wipes instead of toilet paper. -Apply a thin coat of aloe cream to the perineum. -Gently pat the perineum dry after cleansing.
To prevent skin excoriation from frequent bowel movements associated with inflammatory bowel disease, the nurse would encourage good skin care with a mild soap and water and gently patting the area dry after each bowel movement. Using medicated wipes instead of toilet paper and applying a thin coat of aloe cream are appropriate. The client should identify and avoid foods that increase diarrhea. Antibacterial soaps are harsh and should not be used.
A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? -Assess the client's coping and support systems.
The nurse would assess this patient's coping styles and support systems to best provide holistic care. The other options do not address the patient's distress.
After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client's understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) -I might start bicycling and swimming again once my incision has healed." -I will make sure that I make lifestyle changes to prevent constipation." -I will be sure to have the recommended colonoscopies."
ANS: C, D, E The client has had a colon resection for early CRC and there is no indication that the client also had a colostomy. Follow up with recommended colonoscopies are essential to monitor for CRC recurrence. Avoiding constipation will help improve intestinal motility which helps to decrease the risk for CRC recurrence. Exercise and other activities do not need to be restricted after the client has healed.
A nurse cares for a client who has a family history of colorectal cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How would the nurse respond? -You should have a colonoscopy more frequently to identify abnormal polyps early."
ANS: D The nurse would encourage the patient to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the client's diet to more high-fiber (not low-fiber) and preemptive chemotherapy may decrease the client's risk of colon cancer but will not prevent it.
The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) - Cultural food preferences - Increased need for nutrition -Need for NPO status - Staff shortages
Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition.
A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) - Serum potassium of 2.8 mEq/L (2.8 mmol/L) - Abdominal pain in upper quadrants - Serum sodium of 121 mEq/L (121 mmol/L)
ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic (normal range is 136 to 145 mEq/L [136 to 145 mmol/L]). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.