med surg exam 1

The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.)

- Achlorhydria - Chronic atrophic gastritis - Helicobacter pylori infection - Pernicious anemia

A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority?

Assess the clients oxygenation.

After teaching a client with perineal excoriation caused by diarrhea from acute gastroenteritis, a nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?

I will clean my rectal area thoroughly with toilet paper after each stool and then apply aloe vera gel.

After teaching a client who has a femoral hernia, the nurse assesses the clients understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss?

I will put on the truss before I go to bed each night.

After teaching a client who has diverticulitis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

I will take a laxative nightly at bedtime to avoid becoming constipated.

After teaching a client who was hospitalized for Salmonella food poisoning, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

Ill take the ciprofloxacin until the diarrhea has resolved.

An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client?

Increase intake of calcium and vitamin D.

A client is prescribed cetuximab (Erbitux) for oral cancer and asks the nurse how it works. What response by the nurse is best?

It blocks epidermal growth factor.

After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best?

It prevents stress-related ulcers.

To promote comfort after a colonoscopy, in what position does the nurse place the client?

Left lateral

A nurse cares for a teenage girl with a new ileostomy. The client states, I cannot go to prom with an ostomy. How should the nurse respond?

Lets talk to the enterostomal therapist about options for ostomy supplies and dress styles.

A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond?

Lets talk to the ostomy nurse to help you and your husband work through this.

A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?

Metronidazole (Flagyl)

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority?

Notify the health care provider immediately.

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?

Notify the provider immediately.

A client is 1 day postoperative after having Zenkers diverticula removed. The client has a nasogastric (NG) tube to suction, and for the last 4 hours there has been no drainage. There are no specific care orders for the NG tube in place. What action by the nurse is most appropriate?

Notify the surgeon about this finding.

A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client?

Omeprazole (Prilosec)

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?

Pale and bluish stoma

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important?

Performing appropriate hand hygiene

A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)?

Performing frequent oral care

A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene?

Preparing to administer a viscous lidocaine gargle

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?

Remind the client that a small amount of bleeding is possible.

A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority?

Request an electrocardiogram (ECG).

A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?

Respiratory rate

A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding?

Specific lack of protein

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?

Start a large-bore IV with normal saline.

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the clients lower abdomen. Which action should the nurse take first?

Assess for abdominal guarding or rigidity.

A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical manifestation should the nurse expect to find?

High-pitched, rushing bowel sounds in the right lower quadrant

A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?

Hold the feeding until the nausea subsides.

A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are most appropriate? (Select all that apply.)

- Administer the drug through a separate IV line. - Infuse pantoprazole using an IV pump. - Use an in-line IV filter when infusing.

When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.)

- Allow uninterrupted time for eating. - Assess dentures for appropriate fit. - Ensure the client has glasses on when eating. - Serve high-calorie, high-protein snacks.

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.)

- Assess for proper placement of the tube every 4 hours. - Disconnect suction when auscultating bowel peristalsis. - Monitor the clients skin around the tube site for irritation.

The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.)

- Cultural food preferences - Increased need for nutrition - Need for NPO status - Staff shortages

A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (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.

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.)

- Distended abdomen - Inability to pass flatus - Decreased urine output

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

- Encouraging ambulation three times a day - Encouraging normal urination - Providing ice bags and scrotal support

A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.)

- Ensure 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.

After teaching a client with a parasitic gastrointestinal infection, a nurse assesses the clients understanding. Which statements made by the client indicate that the client correctly understands the teaching? (Select all that apply.)

- I must take a shower or bathe every day - I should have my well water tested. - I will ask my sexual partner to have a stool test.

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.)

- Increase the amount of vegetables to 1.1 cups/1000 calories. - Reduce the number of adults who are obese by 10%. - Reduce the consumption of saturated fat by nearly 10%.

A nurse working with a client who has possible gastritis assesses the clients gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.)

- Intolerance of fatty foods - Pernicious anemia

A 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

A nurse teaches a community group about food poisoning and gastroenteritis. Which statements should the nurse include in this groups teaching? (Select all that apply.)

- Rotavirus is more common among infants and younger children - To prevent E. coli infection, dont drink water when swimming. - Parasitic diseases may not show up for 1 to 2 weeks after infection.

After teaching a client with an anal fissure, a nurse assesses the clients understanding. Which client actions indicate that the client correctly understands the teaching? (Select all that apply.)

- Taking a warm sitz bath several times each day - Using bulk-producing agents to aid elimination - Self-administering anti-inflammatory suppositories

A nurse teaches a community group ways to prevent Escherichia coli infection. Which statements should the nurse include in this groups teaching? (Select all that apply.)

- Wash your hands after any contact with animals. - Use separate cutting boards for meat and vegetables.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?

Assess the 24-hour fluid balance.

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond?

A negative fecal occult blood test does not rule out the possibility of colon cancer.

A nurse assesses a clients oral cavity and observes the condition depicted in the photo below: What action by the nurse is best?

Assess the client for dysphagia.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?

Assess the clients bowel sounds.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?

its a good thing I love orange and cherry gelatin.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best?

Assess the clients coping and support systems.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?

Assess the clients gag reflex.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client?

Add vegetables such as broccoli and cauliflower to your new diet.

A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity?

Administer free-water boluses.

A nurse cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first?

Administer intravenous fluids.

A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety?

Agree on a postoperative communication method.

A client has a large oral tumor. What assessment by the nurse takes priority?

Airway

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?

Arrange a dietary consult.

A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best

Ask the client about shellfish allergies.

A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best?

Ask the client if the weight loss was intentional.

A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take?

Ask the health care provider to prescribe the medication as an enema instead.

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first?

Assess and maintain a patent airway.

An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client told about her diagnosis. What action by the nurse is best?

Assess family concerns and fears.

After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu selection made by the client indicates the client correctly understood the teaching?

Baked fish with steamed carrots and a glass of apple juice

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?

Beginning venous thromboembolism prophylaxis

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

Broiled chicken with brown rice, steamed broccoli, glass of apple juice

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client?

Have you been experiencing any constipation?

An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?

Changes in your liver cause drugs to be metabolized differently.

A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important?

Check tube placement before each feeding.

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority?

Cholesterol: 142 mg/dL

A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first?

Client who had a tracheostomy 4 hours ago and needs frequent suctioning

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take?

Contact the provider and recommend computed tomography.

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?

Heart rate and rhythm

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take?

Determine when the client last voided.

A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?

Distended abdomen

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this clients teaching?

Drink plenty of fluids to prevent dehydration.

The nurse reads a clients chart and sees that the health care provider assessed mucosal erythroplasia. What should the nurse understand that this means for the client?

Early sign of oral cancer

A nurse cares for a client who has a new colostomy. Which action should the nurse take?

Empty the pouch frequently to remove excess gas collection.

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate?

Fill out and file a variance report.

A nurse assesses a client who is hospitalized for botulism. The clients vital signs are temperature: 99.8 F (37.6 C), heart rate: 100 beats/min, respiratory rate: 10 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take?

Stay with the client while another nurse calls the provider.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, I need to have a bowel movement. Which action should the nurse take?

Stay with the client while providing privacy.

A client has returned to the nursing unit after an open Nissen fundoplication. The client has an indwelling urinary catheter, a nasogastric (NG) tube to low continuous suction, and two IVs. The nurse notes bright red blood in the NG tube. What action should the nurse take first?

Take a full set of vital signs.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care?

Take a stool softener to promote softer stools for ease of defecation.

A nurse cares for a client with a new ileostomy. The client states, I dont think my friends will accept me with this ostomy. How should the nurse respond?

Tell me more about your concerns.

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 should the nurse respond?

The stool will always be liquid with this type of colostomy.

A client asks the nurse about drugs for weight loss. What response by the nurse is best?

There are three drugs currently approved for this.

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond?

Unfortunately, lubiprostone is approved only for use in women.

A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height?

Use knee-height calipers.

After teaching a client who has a new colostomy, the nurse provides feedback based on the clients ability to complete self-care activities. Which statement should the nurse include in this feedback?

You cleaned the stoma well. Now you need to practice putting on the appliance.

A nurse cares for a client who has a family history of colon cancer. The client states, My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond?

You should have a colonoscopy more frequently to identify abnormal polyps early.

A client is scheduled to have a fundoplication. What statement by the client indicates a need to review preoperative teaching?

after the operation I can eat anything I want.

A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate?

Inform the client a second scan may be needed.

A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.)

- Administer vitamin B12 injections. - Ask the provider about folic acid replacement. - Provide iron supplements for the client.

After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.)

- I will use warm water and a soft washcloth to clean around the stoma. - I might start bicycling and swimming again once my incision has healed. - Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown.

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.)

- Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders - Checks for correct placement by checking the pH of the fluid aspirated from the tube - Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)

- Serum potassium of 2.8 mEq/L - Abdominal pain in upper quadrants - Serum sodium of 121 mEq/L

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this clients plan of care? (Select all that apply.)

- Using premoistened disposable wipes for perineal care - Turning the client from right to left every 2 hours - Applying a barrier cream to the skin after cleaning

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.)

- Which food types cause an exacerbation of symptoms? - Where is your pain and what does it feel like? - Do you experience nausea associated with defecation?

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.)

- chocolate - citrus fruits - peppermint - tomato sauce

A client has a nasogastric (NG) tube. What action by the nursing student requires the registered nurse to intervene?

Pinning the tube to the gown so the client cannot turn the head

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority?

Place the client in a high-Fowlers position.

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?

Provide physical stimulation.

A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first?

Put on a pair of gloves.

A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best?

Slippery elm is often used for this disorder.

The nurse is caring for a client who had an esophagectomy 3 days ago and was extubated yesterday. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

- Assisting with position changes and getting out of bed - Keeping the head of the bed elevated to at least 30 degrees - Taking and recording vital signs per hospital protocol

A client has been discharged to an inpatient rehabilitation center after an esophagogastrectomy. What menu selections by the client at the rehabilitation center indicate a good understanding of dietary instructions? (Select all that apply.)

- Boost supplement - Greek yogurt - Scrambled eggs - Whole milk shake

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.)

- Canned unsweetened apricots - Potato soup

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)

- Cholangitis - Pancreatitis - Perforation - Sepsis

A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.)

- Coal miner - Metal worker - Plumber - Textile worker

The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)

- Colon cancer - Diverticulitis - Inflammatory bowel disease - Peptic ulcer disease

The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.)

- Colonoscopy every 10 years - Computed tomography (CT) colonography every 5 years

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.)

- Delayed gastric emptying - Eating large meals - Hiatal hernia - Obesity

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?

Put on gloves prior to collecting the sample.

A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate?

Report diarrhea to your provider.

The following data relate to an older client who is 2 hours postoperative after an esophagogastrostomy: Physical Assessment Skin dryUrine output 20 mL/hr NG tube patent with 100 mL brown drainage/hr Restless What action by the nurse is best? Vital Signs Pulse: 128 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 20 on ventilator Cardiac output: 2.1 L/min Oxygen saturation: 99% Physician Orders Normal saline at 75 mL/hr Morphine sulfate 2 mg IV push every 1 hr PRN pain Intake and output every hourVital signs every hourVancomycin (Vancocin) 1 g IV every 8 hr

Consult the surgeon about increased IV fluids.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Ensuring siderails are not causing excess pressure

A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?

Enzyme-linked immunosorbent assay (ELISA) toxin A+B

A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client?

Esophageal dilation

A client has been taught about alginic acid and sodium bicarbonate (Gaviscon). What statement by the client indicates that teaching has been effective?

I should take this on a full stomach.

A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This disease is controlling my life. How should the nurse respond?

Lets discuss potential factors that increase your symptoms.

The student nurse studying the gastrointestinal system understands that chyme refers to what?

Liquefied food ready for digestion

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?

Liver

A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met?

Lungs clear after meals and snacks

The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)?

Mucosal barrier fortifier

A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?

Palpate the RUQ last.

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority?

Psychosocial influences on weight

A client has a nasogastric (NG) tube after a Nissen fundoplication. The nurse answers the call light and finds the client vomiting bright red blood with the NG tube lying on the floor. What action should the nurse take first?

Put on a pair of gloves.

A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?

Serum potassium of 2.6 mEq/L

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?

Severe, steady right lower quadrant pain

A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care?

Skin protection

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate?

State That is a violation of client confidentiality.

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?

White blood cell (WBC) count of 1500/mm3

A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?

Willingness to adhere to drug therapy

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.)

- Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall - Ventral hernia Results from inadequate healing of an incision - Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.)

- I just joined a gym, so I hope that helps me lose weight. - I sure hate to give up my coffee, but I guess I have to. - I will eat three small meals and three small snacks a day. - Sitting upright and not lying down after meals will help.

A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this clients teaching? (Select all that apply.)

- Wash leafy vegetables carefully before eating or cooking them. - Wash your hands before and after using the bathroom. - Be sure meat is cooked to the proper temperature. - Avoid eating eggs that are sunny side up or undercooked.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer?

A 72-year-old who eats fast food frequently

After teaching a client who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

I will take this medication with my breakfast each morning.

A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate?

Id like to know what you are feeling now.

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate?

Increase the fiber and water in your diet.

A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately?

International normalized ratio (INR): 4.2

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take?

Encourage the client to verbalize feelings about the diagnosis.

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate?

Ensure adequate staff when moving the client.

A client is scheduled for a traditional esophagogastrostomy. All preoperative teaching has been completed and the client and family show good understanding. What action by the nurse is best?

Assess the clients psychosocial status.

A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?

Client who had an esophagectomy with a respiratory rate of 32/min

For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)?

Client who is pregnant

A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist?

Client who smokes and drinks daily

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?

Client with a potassium level of 2.6 mEq/L

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition?

Client with congestive heart failure

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?

Ensure an adequate airway

A female client hospitalized for an unrelated problem has a large pearly-white lesion on her lip, to which she continues to apply lipstick that she will not remove for inspection. The client refuses to discuss the lesion with the nurse or health care provider. What action by the nurse is best?

Work with the client to establish a trusting relationship.

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.)

- Alcohol - Caffeine - Corticosteroids - Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.)

- Ammonia: liver - Lipase: pancreas

The nurse is caring for a client with sialadenitis. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

- Applying warm compresses - Offering fluids every hour

A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.)

- Ask a second nurse to double-check the blood. - Prime the IV tubing with normal saline. - Take and record a set of vital signs. - Teach the client about reaction manifestations.

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)

- Decreased hydrochloric acid production - Diminished sensation that can lead to constipation - Fat not digested as well in older adults - Pancreatic vessels become calcified

A nurse cares for a client with colon 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 should the nurse respond?

I will make a referral to the United Ostomy Associations of America.