GI EAQ

The nurse is teaching a client who underwent a Whipple procedure regarding the early signs of dumping syndrome. Which information would the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Pallor 2 Sweating 3 Confusion 4 Tachycardia 5 Hypertension

1, 2, 4 (Early clinical manifestations of dumping syndrome that the nurse would include are pallor, sweating, tachycardia, palpitations, and vertigo. The client will exhibit confusion between 1.5 to 3 hours after eating. The client would experience hypotension, not hypertension, due to fluid shifts.)

13. The most reliable indicator for return of peristalsis status post abdominal surgery is... a. Bowel sounds in at least 3 quadrants b. Abdominal x-ray shows lots of air in small intestine c. The patient passed gas in the last 8 hours or stool in the last 12-24 hours d. The client has no drainage from his/her NG tube

c

11. What assessment should you perform in the kidney failure patient receiving tube feeds a. Serum bilirubin b. Urinalysis c. Breath sounds d. Bowel sounds

c (fluid volume overload)

A client is admitted to the hospital with a diagnosis of peptic ulcer. Which common complication would the nurse assess for in this client? 1 Perforation 2 Hemorrhage 3 Pyloric obstruction 4 Esophageal varices

2 (Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease. The complication of gastric perforation usually occurs after, and is not as common as, hemorrhage. Pyloric obstruction is not a common complication of peptic ulcer disease. Esophageal varices occur with portal hypertension, not peptic ulcer disease.)

The nurse administers lactulose to a client with cirrhosis of the liver. Which laboratory test change leads the nurse to determine that the lactulose is effective? 1 Decreased amylase 2 Decreased ammonia 3 Increased potassium 4 Increased hemoglobin

2 (Lactulose destroys intestinal flora that break down protein and, in the process, give off ammonia. In clients with cirrhosis, ammonia is inadequately detoxified by the liver and can build to toxic levels. Amylase levels are associated with pancreatic problems. Increased potassium levels are associated with kidney failure. Hemoglobin is increased when the body needs more oxygen-carrying capacity, such as in smokers, or in high altitudes.)

After a subtotal gastrectomy, a client is returned to the surgical unit. Which is an appropriate nursing action to prevent pulmonary complications? 1 Ambulating the client to increase respiratory exchange 2 Promoting frequent turning and deep breathing to mobilize secretions 3 Maintaining a consistent oxygen flow rate to increase oxygen saturation 4 Keeping a nonrebreather mask in place to ensure adequate oxygenation

2 (To promote drainage of different lung regions, clients should turn every 2 hours. Deep breathing inflates the alveoli and promotes fluid drainage. During physical effort, individuals with abdominal incisions often revert to shallow breathing. Oxygen administration is a dependent function and generally is not required unless there is underlying cardiac or respiratory disease. There is no indication that a nonrebreather mask is needed.)

Neomycin is prescribed for a client with cirrhosis. Which reason will the nurse explain is the purpose for taking this medication? 1 Prevents an infection 2 Limits abdominal distention 3 Minimizes intestinal edema 4 Reduces the blood ammonia level

4 (Reducing the blood ammonia level decreases the effect of bacterial activity on blood and wastes in the gastrointestinal tract. Although neomycin is an aminoglycoside antimicrobial, it is not administered to prevent infection. Neomycin has little or no effect on intestinal edema. Neomycin does not reduce abdominal distention.)

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse will assess for which complications? Select all that apply. One, some, or all responses may be correct. 1 Infection 2 Hyperglycemia 3 ABO incompatibility 4 Electrolyte imbalance 5 Cardiac dysrhythmias

1, 2, 4 (The concentration of glucose in the solution is an excellent culture medium that promotes the growth of microorganisms. Hyperglycemia is a common complication with TPN because of the high-glucose formulas used; blood glucose levels need to be monitored carefully during therapy. TPN formulas may need to be adjusted daily based on the client's daily electrolyte levels. ABO incompatibility is not associated with TPN. Cardiac dysrhythmias are not related to TPN.)

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct. 1 Decreased urine 2 Hypotension 3 Dyspnea 4 Dry mucous membranes 5 Lung crackles 6 Poor skin turgor

1, 2, 4, 6 (Decreased urinary output, hypotension, dry mucous membranes, and poor skin turgor are all symptomatic of dehydration. Dyspnea and crackles in the lungs may be caused by fluid overload.)

The nurse is caring for a client who underwent a Whipple procedure and has started on a soft diet. Which action would the nurse perform first when the client begins to show signs of dumping syndrome? 1 Assess orientation. 2 Assist client to lie down. 3 Decrease carbohydrates. 4 Withhold fluids at meals.

2 (The first action the nurse would perform for a client experiencing dumping syndrome is to assist the client when lying down. Later symptoms of dumping syndrome include confusion, so the nurse would later assess level of orientation. The nurse would decrease the client's intake of carbohydrates and withhold fluids at meals to prevent further episodes of dumping syndrome.)

Which client is at highest risk for the development of colon cancer a. Older white client with irritable bowel syndrome b. Middle aged African American client who smokes cigarettes c. Middle aged Asian client who travels and eats out frequently d. Older American Indian client taking HRT

b

After a client has a total gastrectomy, which necessary treatment does the nurse plan to include in the discharge teaching? 1 Monthly injections of cyanocobalamin 2 Regular daily use of a stool softener 3 Weekly injections of iron dextran 4 Daily replacement therapy of pancreatic enzymes

1 (Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.)

Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct. 1 Tachycardia 2 Hypotension 3 Rigid abdomen 4 Nausea and vomiting 5 Back and shoulder pain

1, 2, 3, 4, 5 (Perforation of an ulcer can cause tachycardia and hypotension (both caused by fluid volume shifts from the vascular compartment to the abdominal cavity). A client with a perforated ulcer would have a hard, rigid abdomen (caused by tensed muscles) and nausea and vomiting. Back and shoulder pain can occur as a result of irritation of the phrenic nerve.)

A client is admitted to the hospital for acute gastritis and ascites secondary to alcohol use and cirrhosis. For which condition is it most important for the nurse to assess in this client? 1 Nausea 2 Blood in the stool 3 Food intolerances 4 Hourly urinary output

2 (Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis. Although food intolerances should be identified, there is no immediate threat to life. Although increased intra-abdominal pressure because of ascites may precipitate nausea, there is no immediate threat to life. Hourly urine output measurements are unnecessary.)

The health care provider prescribes lidocaine to treat a ventricular dysrhythmia in a client with cirrhosis of the liver. Which alterations in the usual lidocaine dosage would the nurse anticipate for this client? 1 Higher than usual dosage to compensate for the impaired liver function 2 Lower than usual dosage because the medication is metabolized at a diminished rate 3 Reduced dosage because other organs will compensate for the sluggish liver 4 Equal dosage to that needed for other clients but used over a shorter duration

2 (Less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary. A dose higher to compensate for the impaired liver function increases the concentration of lidocaine in the blood, leading to toxicity. Lidocaine is metabolized by the liver; other organs cannot assist in the process. This may be life threatening because the client cannot metabolize lidocaine at the required rate, and toxicity may result.)

A client has been taking Naproxen (NSAID) for several months. Which question is the most important to ask a. Have you experienced any constipation - opioids b. Have you had any stomach pain or indigestion c. Have you had any difficulty swallowing d. Have you noticed any weight loss lately

b (NSAIDS damage/limit the mucosal barrier)

In the immediate postoperative period after a gastrectomy, a client's nasogastric tube is draining a light-red liquid. How long should the nurse expect this type of drainage? 1 1 to 2 hours 2 3 to 4 hours 3 10 to 12 hours 4 24 to 48 hours

3 (The trauma of surgery results in some seeping or oozing of blood into the remaining gastric area for 10 to 12 hours until coagulation takes place. It takes more than 4 hours for the coagulation of blood to occur after the trauma of surgery. Light-red drainage that occurs 24 to 48 hours after surgery is abnormal and unexpected; the health care provider should be notified.)

A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. Which is the nursing priority? 1 Implement fall precautions and/or prevention measures. 2 Administer the prescribed antianxiety agent. 3 Confirm correct tube placement. 4 Evaluate the client's laboratory value results.

1 (Measures must be taken immediately to ensure client safety. The administration of an antianxiety medication may be needed, but it is not the priority. Although verifying correct tube placement is important, the nurse should first take measures to ensure client safety. Determining the correlation of laboratory value results with the client's confusion may be helpful, but it is not the priority.)

Which medication may contribute to development of a peptic ulcer in a client receiving immunosuppressive therapy? 1 Prednisone 2 Azathioprine 3 Cyclosporine 4 Cyclophosphamide

1 (Prednisone is a corticosteroid that suppresses inflammatory responses. A side effect of prednisone is the development of peptic ulcers. Azathioprine is an immunosuppressant that may cause anemia. Cyclosporine is an immunosuppressant that may cause nephrotoxicity and hypertension. Cyclophosphamide is an immunosuppressant that may cause hemorrhagic cystitis.)

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. Which topic would the nurse include in the postoperative care teaching? 1 Gastric suction 2 Oxygen therapy 3 Fluid restriction 4 Urinary catheter

1 (After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions that allow healing at the site of anastomosis. Oxygen is not required unless the client experiences a complication necessitating its administration. An intravenous (IV) line to meet fluid needs and replace gastric losses is given to the average client. A urinary catheter may or may not be necessary.)

10. What is the most common complication with tube feedings a. Clogged tube b. Refeeding syndrome c. Tube dislodgment d. Abdominal distension

a

Which finding on an abdominal assessment of an older adult is a normal consequence of aging a. Increased salivation/drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation

d

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is an appropriate choice for a client with this disorder? 1 Ham sandwich with cheese, whole milk, and potato chips 2 Penne pasta, spinach, banana, and decaffeinated iced tea 3 Baked lasagna with sausage, salad, and milkshake 4 Hamburger, french fries, and cola

2 (A client with cirrhosis and ascites will require moderate to low fat and low sodium intake (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.)

The nurse is caring for a client who had a colostomy 36 hours ago. Which nursing intervention is the priority? 1 Keeping an accurate record of oral fluid intake 2 Emphasizing the importance of regulating the diet to form stool 3 Teaching care of the incision and how to perform colostomy irrigations 4 Observing for drainage and the condition of the abdominal stoma

4 (Because of the recent trauma of surgery, hemorrhage and infection at the operative site can occur, so the priority nursing interventions are observing for surgical site drainage and monitoring the abdominal stoma condition. The client will have nothing by mouth until peristalsis returns, so there may not be any oral intake and this is not the priority intervention. Although emphasizing diet regulation to form stool and teaching incision care and colostomy irrigation could be performed at this time, observing for bleeding and infection has a higher priority during the first 48 hours after surgery.)

14. A client with a new diagnosis of advanced pancreatic cancer begins to cry. The best response a. I am so sorry for making you cry b. I can see youre upset. It is ok to cry c. I will step out for a few minutes until you feel better d. I can see I am upsetting you. Lets not discuss this

b

Which lab values would indicate possible liver complications a. Albumin 3.7 b. Serum ammonia 180 c. Bilirubin 1.0 d. AST 30

b

16. A patient with acute pancreatitis has an arm spasm during blood pressure measurements because a. Elevated serum amylase is irritating to the nerves b. Elevated serum lipase levels cause hypoglycemia and seizures c. Decreased serum calcium levels results in muscle atrophy d. Hypoalbuminemia causes muscle weakness and spasm

c

25. To reduce pain in the patient with acute pancreatitis, the nurse should... a. Provide pain medication q4 hr PRN b. Start IV fluids c. Keep patient NPO Give small amounts of high fat foods

c

A client with cirrhosis of the liver has been taking chlorothiazide. The provider adds spironolactone to the client's medication regimen to prevent which condition? 1 Hyponatremia 2 Hypokalemia 3 Ascites 4 Peripheral neuropathy

2 (Spironolactone is a potassium-sparing diuretic often used in conjunction with thiazide diuretics. The provider was prompted to add spironolactone to the chlorothiazide to prevent potassium loss. It stimulates sodium excretion so will not prevent hyponatremia. Spironolactone is a relatively weak diuretic that will not have a significant effect on ascites. Peripheral neuropathy is not a concern in this scenario and spironolactone would not have an effect on it if it was a concern.)

The nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information would the nurse include in the teaching session? Select all that apply. One, some, or all responses may be correct. 1 Adhering to a low-carbohydrate diet 2 Avoiding aspirin and aspirin-containing products 3 Limiting alcohol consumption to two drinks weekly 4 Avoiding acetaminophen and products containing acetaminophen 5 Avoiding coughing, sneezing, and straining to have a bowel movement

2, 4, 5 (Aspirin can damage the gastric mucosa and precipitate hemorrhage when esophageal or gastric varices are present. Acetaminophen is hepatotoxic and should not be used by the client with cirrhosis. The client with cirrhosis should avoid coughing, sneezing, and straining to have a bowel movement. These activities increase pressure in the portal venous system and increase the client's risk of variceal hemorrhage. A high-carbohydrate diet is encouraged as the diseased liver's ability to synthesize and store glucose is diminished. To decrease the risk of complications, the client must abstain from alcohol.)

The nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client makes which statement? 1 "TPN provides supplemental nutrition." 2 "TPN provides short-term nutrition after surgery." 3 "TPN provides total nutrition when gastrointestinal function is questionable." 4 "TPN assists people who are unable to eat but have active gastrointestinal function."

3 (When gastrointestinal (GI) absorption is inadequate, TPN is the nutritional therapy of choice because it provides needed nutrients. TPN usually is used with chronic or long-term therapy, not for short-term therapy. TPN is used for total, not supplemental, nutrition. The response "TPN assists people who are unable to eat but have active gastrointestinal function" is not the indication for TPN; a feeding tube would be used in this instance.)

The nurse provides education for a client with cirrhosis of the liver who has a prolonged prothrombin time and a low platelet count. A regular diet is prescribed. Which instruction would the nurse include in the teaching? 1 Avoid foods high in phytonadione. 2 Check the pulse several times a day. 3 Drink a glass of milk when taking aspirin. 4 Report signs of bleeding no matter how slight.

4 (One of the many functions of the liver is the manufacture of clotting factors; there is interference in this process with cirrhosis of the liver, resulting in bleeding tendencies. The storage of fat-soluble vitamins (A, D, E, and K), water-soluble vitamins (B1, B2, folic acid, and cobalamin), and minerals (including iron) is compromised in cirrhosis; therefore, these nutrients, including phytonadione, should not be limited. Should the client bleed, the pulse rate may be increased, but it is not necessary for the client to check the pulse rate several times daily. A client whose prothrombin time is prolonged and whose platelet count is low should not take aspirin, even with milk.)

30. A patient with cirrhosis has a paracentesis. Which finding would indicate it was successful a. A substantial decrease in BP b. No residual obtained during procedure c. Decrease in post-procedure weight d. Immediate sensation of a need to urinate

c

The nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a prescription for neomycin enemas based on which abnormal laboratory test? 1 Ammonia level 2 Culture and sensitivity 3 White blood cell count 4 Alanine aminotransferase (ALT) level

1 (Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.)

A client reports a loss of 20 pounds (9 kg) in 3 months and black, tarry stools. A colonoscopy is scheduled. Which instructions would the nurse give to prepare the client for this test? 1 The nurse instructs the client that a bland diet will be prescribed for the night before the test. 2 The nurse tells the client not to eat or drink anything the morning of the test. 3 The nurse administers an oil-retention enema just before the test. 4 The nurse explains that the pretest laxative will cause diarrhea after the test.

2 (Eating or drinking the morning of the test could interfere with the test results. A liquid, not bland, diet should be consumed the night before the test. An oil-retention enema will interfere with visualization during the colonoscopy and should not be administered. Diarrhea should not occur after the test.)

On the second day after an abdominoperineal resection, the nurse anticipates that a client's colostomy stoma will have which appearance? 1 Dry, pale pink, and flush with the skin 2 Moist, red, and raised above the skin surface 3 Dry, purple, and depressed below the skin surface 4 Moist, pink, flush with the skin, and painful when touched

2 (The surface of a stoma is a mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. The stoma should be moist, not dry; pale pink indicates a low hemoglobin level. Although some stomas can be flush with the skin, a raised stoma is more common. The stoma should be moist, not dry; purple indicates compromised circulation. A depressed stoma is retracted and unexpected. Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.)

The client asks the nurse, "How will they 'knock me out' for this colonoscopy?" Which response by the nurse correctly describes the route of administration for conscious sedation? 1 "The medicine will be injected into your spine." 2 "You will receive the anesthesia through a face mask." 3 "You will receive medication through an intravenous (IV) catheter." 4 "We will give you an oral medication about 1 hour before the procedure.

3 (Conscious sedation is administered by direct IV injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without the loss of defensive reflexes. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. The oral route of medication administration is commonly used for pediatric clients, not adults.)

A client with a rigid, painful abdomen is diagnosed with a perforated peptic ulcer. A nasogastric tube is inserted, and surgery is scheduled. Before surgery, the nurse would place the client in which position? 1 Sims 2 Flat-lying 3 Semi-Fowler 4 Dorsal recumbent

3 (The semi-Fowler position will localize spilled stomach contents in the lower part of the abdominal cavity. The Sims position will exert pressure on the abdomen, which may be uncomfortable for the client. Lying flat in bed exerts pressure against the diaphragm from abdominal organs; this will inhibit breathing and intensify discomfort. Also, it allows spilled stomach contents to spread throughout the abdominal cavity. The dorsal recumbent position exerts pressure against the diaphragm from abdominal organs; this will inhibit breathing and intensify discomfort. Also, this position allows spilled stomach contents to spread throughout the abdominal cavity.)

Famotidine is prescribed for a client with peptic ulcer disease. Which mechanism of action is a characteristic of this medication? 1 Increases gastric motility 2 Neutralizes gastric acidity 3 Facilitates histamine release 4 Inhibits gastric acid secretion

4 (Famotidine decreases gastric secretion by INHIBITING HISTAMINE at H2 receptors. Increasing gastric motility, neutralizing gastric acidity, and facilitating histamine release are not actions of famotidine.)

Which interventions are the priorities of care to promote client safety directly after esophagogastroduodenoscopy (EGD)? Select all that apply. One, some, or all responses may be correct. 1 Preventing aspiration 2 Reminding the client not to drive 3 Monitoring for signs of perforation 4 Advising the client to use throat lozenges 5 Teaching the client about hoarseness of voice

1, 3 (The priority for care to promote client safety after EGD is to prevent aspiration. Signs of perforation such as bleeding, pain, and fever are also monitored as priority care. Reminding the client not to drive is low priority. The client is advised to use throat lozenges to relieve throat discomfort, which is a low priority care. Hoarseness of voice persists for several days after EGD. The client is taught about hoarseness of voice, which is considered low priority.)

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. Which would the nurse conclude is the most likely cause of the client's ascites? 1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion

1 (The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.)

The nurse is providing care to a client who is receiving enteral feedings via a nasogastric (NG) tube. Which serious complication would the nurse take measures to prevent? 1 Skin breakdown 2 Aspiration pneumonia 3 Retention ileus 4 Profuse diarrhea

2 (Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler, or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.)

The nurse is reviewing the home medication list for a client admitted with peptic ulcer disease (PUD). Which medication would the nurse question? 1 Iron 2 Ibuprofen 3 Famotidine 4 Acetaminophen

2 (Clients with PUD should refrain from taking aspirin or nonsteroidal anti-inflammatory drug (NSAID) products as this can cause gastrointestinal (GI) bleeding. This includes ibuprofen. Iron helps with the production of more red blood cells, and famotidine is an H2 blocker that decreases gastric acid secretion. Acetaminophen does not irritate the GI mucosa and is safe for clients with PUD.)

The nurse is assessing a newly created colostomy stoma. Which finding indicates signs of ischemia? 1 Constipation 2 Purplish stoma 3 Unusual bleeding 4 Mucocutaneous separation

2 (Signs of ischemia and necrosis of the stoma include a dark red, purplish, or black color. Constipation is normal postoperatively from the anesthesia. Unusual bleeding is a complication but does not indicate ischemia. Mucocutaneous separation is a breakdown of the suture line but is not related to ischemia.)

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. The nurse will monitor the client for which adverse medication effect? 1 Bruising 2 Tachycardia 3 Hyperkalemia 4 Hypoglycemia

3 (Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse would monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.)

When providing instructions for a client scheduled for a colonoscopy, which drink would the client need to understand must be avoided for several days before the procedure? 1 Ginger ale 2 Apple juice 3 Lemon-lime soda 4 Cherry Kool-Aid

4 (Clients should avoid red drinks before a colonoscopy to prevent staining of the bowel, which may cause erroneous results. Ginger ale is a clear soft drink that will not alter test results. Apple juice is an acceptable beverage that also may help clear the bowel of stool. Lemon-lime soda is an acceptable drink; clients should select a clear liquid that will not alter test results.)

Which instruction would be included in a discharge plan for a client hospitalized with severe cirrhosis of the liver? 1 The need for a high-protein diet to avoid malnourishment 2 The use of a sedative for relaxation to decrease personal stress 3 The need to increase daily intake of oral fluids 4 The need to report personality changes to the primary health care provider

4 (The damaged liver may cause increased ammonia levels, resulting in central nervous system (CNS) irritation, which produces behavioral changes. A damaged liver does not metabolize protein adequately; a low-protein diet is indicated. Sedatives are detoxified by the liver and are contraindicated in severe hepatic disease. Kidney function is not usually affected.)

During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. Which nursing intervention is the priority? 1 Remaining with the client to monitor status 2 Slowing the infusion rate 3 Notifying the health care provider 4 Obtaining the client's vital signs

2 (The client is likely experiencing pulmonary edema because of a fluid volume excess. The priority intervention is to slow the infusion to a rate sufficient just to keep the vein open. The nurse will then check the client's vital signs before contacting the provider with the client assessment findings. The nurse will then remain with the client to monitor status until stable.)

29. In the patient with acute pancreatitis, which assessment requires immediate nursing intervention a. HR of 105 BPM b. Respiratory rate of 28 BPM c. BP of 102/76 mmHg d. Serum glucose 136 mg/dL

b

During the first 24 hours after a client has had a permanent colostomy created, the nurse observes no drainage from the colostomy. Which circumstance explains this finding? 1 Local edema after the surgery. 2 Absence of intestinal peristalsis. 3 Decreased fluid intake before surgery. 4 Effective function of the nasogastric tube.

2 (Absence of peristalsis is caused by manipulation of abdominal contents and the depressant effects of anesthetics and analgesics. Edema will not interfere with peristalsis; edema may cause peristalsis to be less effective, but some output will result. An absence of fiber has a greater effect on decreasing peristalsis than does decreasing fluids. A nasogastric tube decompresses the stomach; it does not cause cessation of peristalsis.)

A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which type of tube after surgery? 1 Chest 2 Intestinal 3 Nasogastric 4 Gastrostomy

3 (Nasogastric surgery involves the stomach, duodenum, pancreas, and common bile duct; a nasogastric tube removes gastric secretions and prevents distention of the gastrointestinal tract. A chest tube is used to remove air or blood from the chest cavity; the chest is not entered in the Whipple procedure. Intestinal tubes are used for small bowel obstructions; except for the duodenum, the small bowel is not included in the Whipple procedure. A gastrostomy tube is used to deliver nutrients into the stomach of a client who cannot ingest food via the oral route.)

A client with cirrhosis is scheduled for a liver biopsy. The client asks if there are any postprocedural risks. How would the nurse respond? 1 "The major risk is pneumonia." 2 "The major risk is site infection." 3 "The major risk is bleeding." 4 "The major risk is liver failure."

3 (The major postprocedural risk for this client is bleeding. In many clients with liver dysfunction, such as cirrhosis, the liver has lost its ability to synthesize proteins, such as clotting factors. The major postprocedural risks are not pneumonia, infection, or liver failure; bleeding is a higher risk.)

For a client in a limited income house who has Kwashiorkor, which foods are best a. Oatmeal and bananas b. Omelet made with cheddar cheese c. Tomato soup with oyster crackers d. Whole-wheat pasta with tomato sauce

b (protein)

15. The patient with gastric cancer who undergoes a surgical resection will have an NGT... a. Before surgery b. After surgery c. Before and after surgery to remove gastric contents and secretions d. Before and after surgery to reduce edema

c

A client with biliary cirrhosis receives serum albumin therapy. Which action will the nurse take to evaluate the client's response to therapy? 1 Weight daily 2 Vital signs frequently 3 Urine output every half hour 4 Urine albumin level every shift

1 (The increased osmotic effect of therapy increases the intravascular volume and urinary output; weight loss reflects fluid loss. The vital signs will not change drastically; frequently is a nonspecific timeframe. The urinary output is measured hourly; half-hour outputs are insignificant in this instance. A serum, not urine, albumin level is significant; albumin in the urine indicates kidney dysfunction, not liver dysfunction.)

Your patient just had an EGD. The patient tells you that her mouth is dry. Which is your best action a. Keep the client NPO b. Offer the client sips of clear liquids c. Check the patients gag reflex d. Provide the client with a few ice chips

c

18. Your patient has a history of GI bleeds. Which medication order would you question a. Flagyl b. Levaquin c. Tetracycline d. Motrin

d (bleeding risk)

After a subtotal gastrectomy, a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. Which would the nurse determine is the cause of the latter effect? 1 A second, more extensive rise in glucose 2 An overwhelmed insulin-adjusting mechanism 3 A distention of the duodenum from an excessive amount of chyme 4 An overproduction of insulin that occurs in response to the rise in blood glucose

)4 (The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. The insulin-adjusting mechanism is not overwhelmed but responds vigorously, causing rebound hypoglycemia. Dumping syndrome is related to the high glucose content of food, not the amount of food entering the duodenum.

A client has surgery for the creation of a colostomy. Postoperatively, which color would the nurse expect a viable stoma to be? 1 Brick red 2 Pale pink 3 Light gray 4 Dark purple

1 (Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.)

The nurse designs a health education program specifically for a client who had a gastrectomy. The plan would include which information? 1 Explanation about how to limit and prevent dumping syndrome 2 A description of the therapeutic effect of a high-roughage diet 3 A list of foods that cause gas in the intestine and how to avoid them 4 Encouragement to resume previous eating habits as soon as possible

1 (Symptoms of dumping syndrome occur to some degree in about 50% of all individuals who have undergone a gastrectomy. They include weakness, faintness, heart palpitations, and diaphoresis. It is important to explain to the client that such symptoms can be minimized by reclining after meals, eating small meals, and omitting concentrated and highly refined carbohydrates. Modification of roughage is part of the management of intestinal rather than gastric disorders. Gas-forming foods affect the intestines, not the stomach. Eating habits must be modified to prevent rapid emptying of the stomach.)

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? 1 Institute fall prevention and safety measures. 2 Evaluate coping skills. 3 Measure abdominal girth daily. 4 Test stool specimens for blood.

1 (High ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. Although it is important to evaluate the client's coping skills, it is not the priority. Although measuring abdominal girth daily is done to monitor ascites, it is not the priority for a confused client; safety is the priority. Testing stool specimens for blood is not the priority; providing for client safety is the priority.)

The nurse is obtaining a health history from a client with a diagnosis of peptic ulcer disease. The nurse identifies a possible contributory risk factor when the client makes which statement? 1 "My blood type is A positive." 2 "I smoke one pack of cigarettes a day." 3 "I have been overweight most of my life." 4 "My blood pressure has been high lately."

2 (Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. Blood type O is more frequently associated with duodenal ulcer, but type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.)

Which finding would indicate that the prescribed enteral feeding has been effective in a malnourished client who had head and neck surgery for pharyngeal cancer? 1 Good skin turgor 2 Normal bowel sounds 3 Well-healed incisions 4 Normal appearing stools

3 (Many clients with head and neck cancer are poorly nourished, leading to risk for poor wound healing. Enteral feedings are frequently ordered in the postoperative period to improve wound healing and decrease infection risk. Good skin turgor is an indicator of adequate hydration; intravenous fluids are a better source of fluid than enteral feedings. Normal bowel sounds indicate peristalsis, but are not an indicator that enteral feedings have been effective. Normal appearing stools indicate that the intestinal tract is functioning normally, but are not a therapeutic effect of enteral feedings.)

To prepare a client for discharge, the nurse provides dietary education for a client who had a pancreaticoduodenectomy (Whipple procedure). Which would the nurse include in the instructions? 1 The surgery has established normal digestive processes; no dietary restrictions are needed. 2 To prevent overworking the pancreas, follow a low-calorie diet. 3 Because of compromised liver function, restrict protein intake. 4 The surgery has interfered with the fat digestion mechanism; a low-fat diet is needed.

4 (A pancreaticoduodenectomy leads to malabsorption because of impaired delivery of bile to the intestine; fat metabolism is interfered with, causing dyspepsia. These clients are anorexic, require small, frequent meals, and should eat a high-calorie, high-protein, low-fat diet. High-calorie meals are needed for energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless direct extension occurs.)

9. A client on TPN complains of blurred vision, dry mouth, and frequency. What is the best action a. Weighing the client b. Assessing the client's blood sugar level c. Assessing the clients vital signs d. Slowing down the TPN infusion

b

12. What lab value would you monitor closely in your patient receiving tube feeds and insulin a. Creatinine b. Phosphorus c. Potassium d. Calcium

c (Insulin carries glucose and potassium out of the vascular space into the cells. This can deplete K)

19. A patient arrives to the ER shot in the abdomen and is bleeding heavily. Which action should be first? a. Send a blood sample for type and crossmatch b. Obtain the heart rate and blood pressure c. Insert a large bore IV line for fluid resuscitation d. Assess and maintain a patent airway

d

23. A patient has an upper GI bleed and NG tube, what comfort measure may the nurse delegate to the UAP a. Taking and recording vital signs b. Lavaging the tube with ice water c. Re-positioning the tube every 4 hours d. Performing frequent oral care

d

27. In a patient with acute pancreatitis, which intervention should be implemented for pain relief a. PCA morphine sulfate b. Oral Dilaudid c. PCA meperidine d. IM Fentanyl

a

The nurse is caring for a client who just returned from an esophagogastroduodenoscopy (EGD) and directs the unlicensed assistive personnel (UAP) to get the client settled in the room. Which action made by the UAP is incorrect? 1 Raising the head of bed 2 Straightening bed linens 3 Obtaining vital signs 4 Offering client water

4 (After an EGD, the client should not have any food or drink until the gag reflex has returned. Therefore, the nurse would correct the UAP to not offer the client water. Raising the head of bed, straightening bed linens and obtaining vital signs are acceptable tasks to perform.)

21. A patient with acute pancreatitis states "I am hungry," how should the nurse reply a. Is you stomach rumbling, or do you have bowel sounds b. You will not be able to eat until the pain subsides c. Have you passed flatus or moved your bowels d. I need to check your gag reflex before you can eat

c

24. A nurse cared for a patient recovering from an open Whipple. What action should the nurse take a. Clamp the NG tube b. Provide oral rehydration c. Place the client in semi-fowlers position d. Assess vital signs once every shift

c

28. When teaching nutrition to a patient with acute pancreatitis you should include a. Expect some nausea and vomiting as you begin to consume food b. Low carb, high protein, high fat foods should be consumed - should be low fat c. Small frequent meals d. Alcohol and caffeine should be consumed moderately

c

Which nursing assessment findings are consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. 1 Pulse quality 2 Pulse pressure 3 Bounding pulse 4 Presence of dependent edema 5 Neck vein distention in the upright position

3, 4, 5 (Bounding pulse, presence of dependent edema, and neck vein distention in the upright position are all indicators of fluid overload, which should be reported by the nurse. Pulse quality and pulse pressure are indicators to monitor the client's response to fluid therapy.)

When checking placement of a feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. Which would the nurse do next? 1 Notify the provider. 2 Advance the tube 1 cm. 3 Insert 1 mL of formula slowly. 4 Try aspirating stomach contents.

4 (Gastric returns indicate correct placement of the feeding tube. Further assessment is necessary before the provider is notified. Advancing the tube even 1 cm may cause undue trauma, regardless of where the tube is located. Inserting even a small amount of formula is unsafe until correct placement is verified; formula may enter the lungs if the tube is not in the stomach.)

20. Prolonged prothrombin time is probably a dysfunction in which organ a. Liver b. Spleen c. Kidneys d. Stomach

a (liver makes clotting factors)

The health care provider prescribes 1000 mL of total parenteral nutrition (TPN) to be administered in 12 hours. Based on this prescription, how many milliliters of solution will be administered per hour? 1 83 mL/h 2 100 mL/h 3 108 mL/h 4 125 mL/h

1 (83 mL/h is the correct calculation. 1000 mL of solution divided by 12 hours equals 83.3 mL/h. Always round to the nearest whole number. 100 mL/h is an incorrect calculation; it is too much solution per hour. 108 mL/h is an incorrect calculation; it is too much solution per hour. 125 mL/h is an incorrect calculation; it is too much solution per hour.)

After a subtotal gastrectomy, a client has a nasogastric (NG) tube in place for continuous low suction. Three hours after the surgery, the client experiences nausea and abdominal pain. The client's abdomen appears distended. Which action would the nurse take? 1 Instill 30 mL of air into the NG tube. 2 Administer the prescribed pain medication. 3 Inform the client that abdominal pain is common with NG tubes. 4 Notify the health care provider immediately.

1 (Abdominal distention, nausea, and abdominal pain can be signs of nasogastric tube blockage. Instilling 30 mL of air may reestablish patency. Although opioids usually are prescribed postoperatively, they tend to decrease peristalsis and may increase abdominal distention and nausea. It is not common for NG tubes to cause abdominal pain. The nurse should evaluate the cause of the symptoms before notifying the health care provider. If patency is reestablished, it will most likely relieve the symptoms and notification of the health care provider will not be necessary.)

The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? 1 Clear breath sounds 2 Positive pedal pulses 3 Normal potassium level 4 Decreased urine specific gravity

1 (Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective. Although it may make palpation more difficult, excess fluid will not diminish pedal pulses. A normal potassium level can be maintained independently of fluid excess correction. As the client excretes excess fluid, the urine specific gravity will increase, not decrease.)

A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain? 1 Infusion pump 2 Tall intravenous (IV) pole 3 Clamp that will be taped at the bedside 4 Infusion set that delivers 60 drops/mL

1 (Hypertonic solution should be administered in an infusion pump for continuous and uniform infusion to prevent hyperosmolar diuresis or fluctuations in glucose. The height of the IV pole is not as significant as the stability needed to safely support the infusion pump. There is no reason to keep a clamp at the bedside. The tubing set should be appropriate for the type of infusion pump being used.)

A client is receiving total parenteral nutrition (TPN) through a central venous access device. Which important nursing intervention will be included? 1 Placing the client in the supine position before changing the tubing 2 Monitoring the blood pressure frequently to assess for hypovolemia 3 Decreasing the infusion rate if blood glucose levels become elevated 4 Piggybacking intravenous antibiotics onto the TPN tubing to prevent infection

1 (Placing the client in the supine position before changing the tubing decreases pressure in the vena cava, which helps prevent an air embolus when the catheter is disconnected. Infusion of high concentrations of glucose will cause hypervolemia, not hypovolemia. The infusion rate is changed only with a health care provider's prescription. Although insulin is contained in the parenteral nutrition formula, when blood glucose levels become elevated the health care provider may prescribe insulin coverage. No medications or solutions other than the parenteral nutrition should be administered through this line.)

Which action would the nurse take when administering total parenteral nutrition (TPN)? 1 Change the TPN solution bag every 24 hours, even if there is solution left in the bag. 2 Monitor the client's blood glucose level every 2 hours at the bedside with a glucometer. 3 Instruct the client to breathe shallowly when changing the TPN tubing using sterile techniques. 4 Speed up the rate of the TPN infusion if the amount delivered has fallen behind the prescribed hourly rate.

1 (TPN solutions are high in glucose and are administered at room temperature, factors that increase the risk of microbial growth in the solution; they should be changed daily or sooner if they appear cloudy. Monitoring the blood glucose level every 2 hours is too frequent in ordinary circumstances; the client's blood glucose level should be monitored every 4 to 6 hours to identify the presence of hyperglycemia, a metabolic complication of TPN. The client should not breathe while the TPN catheter is changed because it may result in an air embolus; the Valsalva maneuver should be performed by the client for the few seconds it takes to switch the tubing. An excess amount of glucose will be infused if the rate of the TPN is increased, and the endogenous insulin will be inadequate to meet this demand, resulting in hyperglycemia.)

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for the procedure? 1 Instruct the client to void. 2 Tell the client not to eat for 4 hours. 3 Give the client an analgesic. 4 Have the client turn to the lateral position.

1 (The bladder must be emptied to avoid trauma during insertion of the trocar. Giving the client an analgesic is not necessary. Systemic analgesics may mask the symptoms of shock, a potential complication. The semi-Fowler position is used to allow fluid to accumulate in the lower abdominal cavity so that it can be accessed by the trocar.)

A client is diagnosed with acute gastritis secondary to alcoholism and cirrhosis. The client reports frequent nausea, pain that increases after meals, and black, tarry stools. The client recently joined Alcoholics Anonymous. The nurse would give priority to which client history item? 1 Black, tarry stools 2 Frequent nausea 3 Joining Alcoholics Anonymous 4 Pain that increases after meals

1 (The priority is black, tarry stools, which indicate upper gastrointestinal (GI) bleeding; digestive enzymes act on the blood, resulting in tarry stools. Hemorrhage can occur if erosion extends to blood vessels. Nausea is a common symptom of gastritis but is not life threatening. Attempts to control alcoholism should be supported, but this is a long-term goal; assessment of bleeding takes priority. Investigation of bleeding takes priority; later the nurse should help identify irritating foods that may be increasing the pain after eating and are to be avoided.)

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration? 1 Elevate the head of the bed between 30 and 45 degrees. 2 Decrease flow rate at night. 3 Check for residual daily. 4 Irrigate regularly with warm tap water.

1 (To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not prevent aspiration.)

The nurse is administering medications via gastrostomy tube to an older client in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? Select all that apply. One, some, or all responses may be correct. 1 Absence of bowel sounds 2 Presence of abdominal distension 3 Residual capacity exceeding 300 mL 4 Positive guaiac test of abdominal contents 5 Seepage of feeding around tracheostomy

1, 2, 3, 4, 5 (Monitoring toleration of medications and feeding is significant for the client with a gastrostomy tube. In older adults, abdominal distension may be caused by excess feeding administration rates, delayed gastric emptying, or decreased bowel motility. Bowel sounds are an indication of gastrointestinal activity. Absent bowel sounds could be caused by ileus or bowel obstruction. Positive guaiac from abdominal contents indicates bleeding. Seepage of feeding solution around a tracheostomy tube may be caused by gastric reflux, placing the client at risk for aspiration. Residual capacity or gastric residual is usually assessed every 8 hours. A residual volume twice the infusion rate is considered abnormal and would be reported to the health care provider.)

The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations would the nurse assess in the client? Select all that apply. One, some, or all responses may be correct. 1 Ascites 2 Hunger 3 Pruritus 4 Jaundice 5 Headache

1, 3, 4 (Ascites is a result of portal hypertension that occurs with cirrhosis. Pruritus is common because bile pigments seep into the skin from the bloodstream. Jaundice occurs because the bile duct becomes obstructed and bile enters the bloodstream. The appetite decreases because of the pressure on the abdominal organs from the ascites and the liver's decreased ability to metabolize food. Headache is not a common manifestation of cirrhosis of the liver.)

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy would the nurse assess this client? Select all that apply. One, some, or all responses may be correct. 1 Mental confusion 2 Increased cholesterol 3 Brown-colored stools 4 Flapping hand tremors 5 Musty, sweet breath odor

1. 4. 5 (An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. An accumulation of nitrogenous wastes in hepatic encephalopathy affects the nervous system. Flapping tremors and generalized twitching occur in the second and third stages, respectively. Fetor hepaticus is the musty, sweet odor of the client's breath. Increased cholesterol levels are not necessarily present. Stool is often clay-colored because of lack of bile caused by biliary obstruction.)

The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. Which action would the nurse take? 1 Clamp the tube. 2 Consider this an expected event. 3 Instill the tube with iced normal saline. 4 Notify the health care provider immediately

2 (Because of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.)

Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective? 1 Urine output over 1 hour is 200 mL. 2 Oxygen saturation per pulse oximetry is 99%. 3 Cardiac monitor shows sinus rhythm, rate 98 beats/minute. 4 No jugular vein distention is seen with head elevated to 90 degrees.

2 (Because pulmonary congestion associated with pulmonary edema causes severe hypoxemia, the client's oxygen saturation is the best indicator of effective treatment. A good urine output also shows that furosemide is effective, but is not as clear an indicator of improvement in pulmonary edema as the high oxygen saturation. Tachycardia is a common finding with pulmonary edema and having a heart rate in the high normal range may indicate improvement in the client's condition, but improvement in pulmonary parameters is a better indicator for this client. Jugular vein distension is an indicator of right heart failure, whereas pulmonary edema is caused by left ventricular failure.)

When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take? 1 Perform a finger stick glucose test and call the primary health care provider with the results. 2 Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. 3 Discontinue the infusion and flush the intravenous (IV) line with saline solution until the next TPN bag is ready. 4 Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

2 (Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse would infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the health care provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless a negative client outcome results.)

After reviewing the morning laboratory reports, which client would the nurse suspect as having peptic ulcer disease? 1 A: Haemophilus influenzae 2 B: H. Pylori 3 C: Pseudomonas aeruginosa 4 D: staphyloccus aureus

2 (Helicobacter pylori (observed in client B) is a bacterium infecting the gastrointestinal tract and causes peptic ulcers and gastritis. Haemophilus influenzae (observed in client A) may cause nasopharyngitis, meningitis, or pneumonia. Pseudomonas aeruginosa (observed in client C) may cause urinary tract infections and meningitis. Staphylococcus aureus (observed in client D) may cause skin infections, pneumonia, urinary tract infections, acute osteomyelitis, and toxic shock syndrome.)

Which finding in a client with pulmonary edema requires the most rapid action by the nurse? 1 Weak, rapid pulse 2 Oxygen saturation 82% 3 Blood pressure 99/54 mm Hg 4 Crackles throughout both lungs

2 (Oxygen saturation less than 90% indicates hypoxemia, which affects functioning of all tissues and organs and needs to be quickly corrected through administration of high oxygen levels, typically via non-rebreather mask. The other findings are also of concern but are not as essential as correcting hypoxemia. A weak, rapid pulse and low blood pressure occur in pulmonary edema because of decreased left ventricular function and poor cardiac output. The blood pressure indicates that cardiac output is currently low but adequate to perfuse tissues. Crackles heard throughout both lungs are consistent with pulmonary edema and need to be rapidly treated with diuresis, after oxygen is started to correct hypoxemia.)

Which pathophysiological rationale explains why a client who is 4 days postabdominal surgery has not passed flatus and has hypoactive bowel sounds and why a paralytic ileus is suspected of developing? 1 Decreased blood supply 2 Impaired neural functioning 3 Perforation of the bowel wall 4 Obstruction of the bowel lumen

2 (Paralytic ileus occurs when neurological impulses diminish and is a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.)

Which is the priority intervention for a dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood? 1 Apply oxygen. 2 Place the client in a side-lying position. 3 Prepare to administer packed red blood cells. 4 Assess the client's pulse and blood pressure.

2 (Recall the airway-breathing-circulation (ABCs) of priority care. The client who needs assistance to manage self-care (dependent) should be placed in the side-lying position when vomiting to prevent aspiration. The use of supplemental oxygen may support oxygen saturation in the client with decreased hemoglobin because of gastrointestinal bleeding. However, in the dependent client who is vomiting, applying oxygen is of lower priority than placing the client in a side-lying position. The nurse should anticipate a prescription for packed red blood cells in the client with a significant gastrointestinal bleed. Restoring circulation, however, is of lower priority than protecting the airway in a dependent client whose airway is at risk. The immediate physical examination of the client with active gastrointestinal bleeding includes evaluation of vital signs as a means of assessing for shock. Assessing for adequate circulation would not take priority over protecting the airway.)

Which information would be included in the teaching plan for the older adult client with peptic ulcer disease who is taking an antacid and sucralfate? 1 Antacids should be taken 30 minutes before a meal. 2 Sucralfate should be taken on an empty stomach 1 hour before meals. 3 Sucralfate is prescribed for the long-term maintenance of peptic ulcer disease. 4 Sodium bicarbonate is an inexpensive over-the-counter antacid with few adverse effects.

2 (Sucralfate works best in a low pH environment; therefore it should be given on an empty stomach either 1 hour before or 2 hours after meals. Sucralfate also should be administered no sooner than 30 minutes before or after an antacid. The acid-neutralizing effects of antacids last approximately 30 minutes when taken on an empty stomach and 3 to 4 hours when taken after meals. When sucralfate and an antacid are both prescribed, they are each most effective when the sucralfate is scheduled an hour before meals and the antacid is scheduled after meals. Sucralfate is prescribed for the short-term treatment of peptic ulcers. Its use is limited to 4 to 8 weeks. The client should follow the recommendations of the primary health care provider with regard to antacid selection. Sodium bicarbonate can produce acid-base imbalances, which could be harmful, especially in older adult clients.)

For the client receiving total parenteral nutrition (TPN), which action will the nurse take to prevent a major complication? 1 Flush the line if extravasation occurs. 2 Administer the infusion over 12 to 24 hours. 3 Change the site every 24 hours. 4 Discontinue the infusion immediately if elevation of hepatic enzymes occurs.

2 (TPN should be infused at a slow, constant rate; this will prevent both hyperglycemia and cellular dehydration from too rapid infusion of a hypertonic solution. The intravenous (IV) line should not be flushed if extravasation occurs. Generally, a major vein is selected for administration of TPN; the site is not changed every 24 hours. Abruptly discontinuing the infusion can lead to rebound hypoglycemia; elevation of hepatic enzymes is an anticipated adverse effect in 1% to 2% of clients.)

Immediately after the insertion of a subclavian central venous access catheter, which is the priority nursing action for a client who is to begin total parenteral nutrition (TPN)? 1 Obtain a chest x-ray to determine placement. 2 Auscultate the lungs to evaluate breath sounds. 3 Draw a blood sample to assess blood glucose level. 4 Assess the right upper extremity for neurological deficits.

2 (The most significant and life-threatening complication of the insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client's respiratory status always is the priority. Although a chest x-ray may be done before TPN is begun, it is not the priority immediately after the insertion of the catheter. A baseline blood glucose level should be obtained before the insertion of the catheter. After TPN is started, routine monitoring of blood glucose levels is important. Although assessing for a neurological deficit should be done eventually, it is not the priority at this time.)

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action would the nurse take first? 1 Instill normal saline into the tube to maintain patency. 2 Obtain an x-ray to verify that the tube is in the stomach. 3 Auscultate the epigastric area while instilling 30 mL of air. 4 Withdraw stomach contents to observe color and consistency.

2 (X-ray verification of tube placement is required before anything is instilled into the nasogastric tube. Administering a feeding through a misplaced tube can cause the formula to enter the client's lungs. Instilling normal saline into the tube to maintain patency is unsafe. The normal saline will enter the client's lungs if the tube is in the wrong place. Auscultating the epigastric area while instilling 30 mL of air and withdrawing a small amount of stomach contents to verify tube placement are not definitive ways to ensure correct placement of the nasogastric tube. Once placement is verified by an x-ray, these methods may be used before initiating a feeding.)

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse would include which instructions about minimizing dumping syndrome? Select all that apply. One, some, or all responses may be correct. 1 Drink fluids with meals. 2 Eat small, frequent meals. 3 Lie down for 1 hour after eating. 4 Chew food five times before swallowing. 5 Select foods that are low in fiber.

2, 3 (Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.)

A client is evaluated at a clinic, and the health care provider suspects that the client has anemia and a peptic ulcer. To determine if the client has a peptic ulcer, the nurse expects that which diagnostic test will be performed? 1 Barium enema 2 Gastric biopsy 3 Gastric culture 4 Stool examination

3 (A gastric culture enables the health care provider to identify the presence of Helicobacter pylori. Two-thirds of individuals with gastric or duodenal ulcers are infected with this organism. A barium enema outlines structural changes in the lower gastrointestinal tract; it will not outline the stomach or duodenum. A gastric biopsy is done to identify the presence of malignant cells. A stool examination may identify melena or parasites, but it is not definitive for peptic ulcers.)

A client has a surgically created colostomy. Which is the most effective nursing intervention initially to help the client accept the colostomy? 1 Provide literature containing factual data about colostomies. 2 Ask a member of a support group to come to speak with the client. 3 Begin to teach self-care of the colostomy by introducing equipment. 4 List the names of important people who have had colostomies.

3 (Beginning with equipment is less threatening and may stimulate feelings of mastery. Providing literature containing factual data about colostomies may be helpful, but introducing needed equipment will be more likely to provide the client with initial acceptance. Asking a member of a support group to come to speak with the client is helpful but may take time and may not meet immediate needs. Listing important people who have had colostomies may be helpful but is not an initial step to take toward the client's acceptance of the colostomy.)

The nurse is preparing to assess a client with peptic ulcer disease (PUD). Which assessment finding indicates a need for immediate health care provider notification? 1 Nausea 2 Dyspepsia 3 Black stools 4 Dull abdominal pain

3 (Black stools indicate the presence of blood in the stool and needs to be immediately reported to the health care provider. Nausea, dyspepsia, and dull abdominal pain are minor clinical manifestations and can be managed with medications.)

A client returns from surgery with a permanent colostomy. During the first 24 hours, the colostomy would not drain. Which would the nurse determine is the probable cause of this response, and which is the corresponding treatment? 1 Intestinal edema after surgery; apply ice 2 Presurgical decrease in fluid intake; encourage fluids 3 Absence of gastrointestinal motility; continue to monitor 4 Effective functioning of nasogastric suction; irrigate stoma

3 (The colostomy starts functioning when peristalsis returns. Intestinal manipulation and the depressive effects of anesthesia and analgesics cause absence of gastrointestinal motility; this is an expected response, so continue to monitor. Edema will not interfere totally with peristalsis; there should be some output. Ice will damage the stoma. A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. A nasogastric tube decompresses the stomach; it would not directly influence intestinal motility at this time. Irrigation is not necessary.)

Which action by the nurse would prevent aspiration when administering medications through a nasogastric tube? Select all that apply. One, some, or all responses may be correct. 1 Placing the client in the supine position 2 Keeping the head of the bed elevated 20 degrees 3 Assessing residual capacity and discarding the contents 4 Verifying placement of the nasogastric tube 5 Placing the client in the left-lateral Sims position after administration

4 (Actions to prevent aspiration in clients receiving medications via the nasogastric route include verifying placement of the nasogastric tube before instilling medications. The client would be placed in the high Fowler position when administering medications. It is important to check residual capacity before administering medications or feedings via a nasogastric tube; however, the gastric contents would be returned to prevent dangerous alterations in fluid and electrolyte values. Keeping the head of the bed elevated 20 degrees would not prevent aspiration. The head of the bed would be elevated 60 to 90 degrees for administration of medications or feeding. Placing the client in the left-lateral Sims position may increase gastric emptying but would not prevent aspiration.)

A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which condition results from this imbalance? 1 Hemorrhage with subsequent anemia 2 Diminished resistance to bacterial insult 3 Malnutrition of cells, especially hepatic cells 4 Reduction of colloidal osmotic pressure in the blood

4 (Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.)

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention? 1 Weigh the client daily. 2 Restrict the client's oral fluid intake. 3 Measure the client's urine specific gravity. 4 Observe the client for increasing confusion.

4 (An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.)

A health care provider prescribes sodium biphosphate for a client before a colonoscopy. How would the medication accomplish its therapeutic effect? 1 Irritates the intestinal mucosa 2 Provides water-absorbing bulk 3 Softens stool by exerting a detergent effect 4 Increases osmotic pressure in the intestines

4 (Sodium biphosphate is a saline (hypertonic) cathartic that increases osmotic pressure within the intestine so that body fluids are drawn into the bowel, stimulating bowel stretching, peristalsis, and defecation. Intestinal stimulants increase peristalsis by irritating the mucosa. Bulk-forming laxatives are cellulose derivatives that remain in the intestinal tract and absorb water; they stimulate peristalsis by increasing bulk. Emollients have a detergent action, softening stool by facilitating its absorption of water.)

A client with severe cirrhosis is hospitalized. The nurse discovers fetor hepaticus when the nurse performs which part of the client's assessment? 1 Assessment of the client's urine 2 Assessment of the client's stool 3 Assessment of the client's hands 4 Assessment of the client's breath

4 (The client's breath has a sweet odor (fetor hepaticus) because the liver is not metabolizing the food, especially proteins. The urine is dark. The stool is clay-colored. The hands develop asterixis or flapping tremors)

Which statement explains why total parenteral nutrition (TPN) is infused through a central line rather than a peripheral line? 1 It prevents the development of infection. 2 There is less chance of this infusion infiltrating. 3 It is more convenient, so clients can use their hands. 4 The large amount of blood helps dilute the concentrated solution

4 (Unless diluted by the increased blood flow, the highly concentrated solution can cause injury to the veins. The potential of infection is high with TPN because of the increased glucose levels. The other options are not the primary reason, although the infusion at this site is more secure and promotes free use of the arms and hands.)

The nurse is performing a physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expects to observe which skin conditions? Select all that apply. One, some, or all responses may be correct. 1 Vitiligo 2 Hirsutism 3 Melanosis 4 Ecchymoses 5 Telangiectasia

4, 5 (Ecchymoses are small areas of bleeding into the skin or mucous membrane, forming a blue or purple patch. With cirrhosis there is decreased synthesis of prothrombin in the liver. Telangiectasia is a vascular lesion formed by dilation of a group of small blood vessels. When cirrhosis causes an increase in pressure in the portal circulation that results in a dilation of cutaneous blood vessels around the umbilicus, it is specifically called caput medusae. Vitiligo refers to patches of depigmentation resulting from destruction of melanocytes. Hirsutism is excessive growth of hair; with cirrhosis, endocrine disturbances result in loss of axillary and pubic hair. Dark pigmentary deposits, or melanosis, result from a disorder of pigment metabolism.)

22. A patient having an EGD was given Versed. The patients respiratory rate is 8 BPM. What nursing action is best a. Provide physical stimulation b. Ventilate with a bag-valve mask c. Administer Naloxone (Narcan) d. Call the rapid response team

a

An older adult is scheduled for a double contrast barium enema. What is the priority teaching a. Be sure to take the laxative as prescribed after the test b. Drink a gallon of GoLYTELY the day before the test c. Do not take food or fluids for 24 hours before the test d. Tell the nurse if you have flatus after the test is complete

a

17. The first priority for a patient with an upper GI bleed is a. Start 2 large bore IVs and initiate fluids (NS or LR) b. Check that the patients airway is clear c. Start 2 large bore IVS and initiate blood transfusion d. Draw a stat Hbg and Hct

b

26. The critical care nurses first priority in the patient with acute pancreatitis is a. Insert an NG tube b. Administer IV fluids and electrolytes c. Insertion of a Foley catheter d. Encouragement of oral fluid intake

b

Which statement shows that the client needs additional teaching about his colonoscopy a. I may have gas and abdominal cramps after the test b. I will take strong laxatives the afternoon before the test c. I will take my Coumadin with a sip of water tomorrow morning d. I will be NPO after midnight on the day of the test

c