Med Surg Gastrointestinal NCLEX Questions
A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? A. Ileum B. Cecum C. Rectum D. Jejunum
B. Cecum Rationale: The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex
4. Assessing for the return of the gag reflex Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.
The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? A. "Baked foods such as chicken or fish are all right to eat." B. "Citrus fruits and raw vegetables need to be included in my daily diet." C. "I can drink beer as long as I consume only a moderate amount each day." D. "I can drink coffee or tea as long as I limit the amount to 2 cups daily."
A. "Baked foods such as chicken or fish are all right to eat." Rationale: Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food.
A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? A. "I eat at least 3 large meals each day." B. "I eat while lying in a semirecumbent position." C. "I have eliminated taking liquids with my meals." D. "I eat a high-protein, low- to moderate-carbohydrate diet."
A. "I eat at least 3 large meals each day." Rationale: Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention? A. Notify the health care provider (HCP). B. Administer the prescribed pain medication. C. Call and ask the operating room team to perform surgery as soon as possible. D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
A. Notify the health care provider (HCP). Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain
A. Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? A. Vitamin B12 injections B. Vitamin B6 injections C. An antibiotic D. An antacid
A. Vitamin B12 injections Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.
The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? A. The client reports some pain before meals. B. The client frequently is awakened at 2 a.m. with heartburn. C. The client has eliminated any irritating foods from the diet. D. The client's pain is minimal with histamine H2-receptor antagonists.
C. The client has eliminated any irritating foods from the diet. Rationale: Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.
The nurse is caring for a client admitted to the hospital with suspected acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? A. White blood cell (WBC) count of 4000 mm3 (4 × 109/L) B. WBC count of 8000 mm3 (8 × 109/L) C. WBC count of 18,000 mm3 (18 × 109/L) D. WBC count of 26,000 mm3 (26 × 109/L)
C. WBC count of 18,000 mm3 (18 × 109/L) Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the WBC count (leukocytosis) to 10,000 to 18,000 mm3 (10 to 18 × 109/L) with an increased number of immature WBCs. An inflammatory process causes a rise in the WBC count. A rise to 26,000 mm3 (26 × 109/L) may indicate a perforated appendix (greater than 20,000 mm3 [20 × 109/L]).
The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? A. "It's due to insufficient production of vitamin B12 in the colon." B. "Increased production of intrinsic factor in the stomach leads to this type of anemia." C. "Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." D. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine."
D. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine.
The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement? A. "It will help to provide me with nourishment." B. "It will help to relieve the congestion from excess mucus." C. "It is used to remove gastric contents for laboratory testing." D. "It will help to remove gas and fluids from my stomach and intestine."
D. "It will help to remove gas and fluids from my stomach and intestine." Rationale: Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? A. Bradycardia B. Numbness in the legs C. Nausea and vomiting D. A rigid, boardlike abdomen
D. A rigid, boardlike abdomen Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance
D. Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? A. "I plan to eat 4 to 6 small meals a day." B. "I should sleep in the right side-lying position." C."I plan to have a snack 1 hour before going to bed." D. "I will stop having a glass of wine each evening with dinner."
C."I plan to have a snack 1 hour before going to bed." Rationale: The control of GERD involves lifestyle changes to promote health and control reflux. These include eating 4 to 6 small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night.
The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which client statement supports the diagnosis of gastric ulcer? A. "The pain doesn't usually come right after I eat." "B. The pain gets so bad that it wakes me up at night." C. "The pain that I get is located on the right side of my chest." D. "My pain comes shortly after I eat, maybe a half-hour or so later."
D. "My pain comes shortly after I eat, maybe a half-hour or so later." Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.
A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? A. "Do you want to stay here in this facility for a few more days?" B. "Have you discussed your feelings with your health care provider?" C. "You need to talk to your health care provider about these concerns." D. "Tell me more about your concerns with your diet after going home."
D. "Tell me more about your concerns with your diet after going home." Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about . . ." often leads to valuable information about the client and his concerns. The statements in the remaining options are nontherapeutic.
The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? A. "I need to limit my intake of dietary fiber." B. "I need to drink plenty, at least 8 to 10 cups daily." C. "I need to eat regular meals and chew my food well." D. "I will take the prescribed medications because they will regulate my bowel patterns."
A. "I need to limit my intake of dietary fiber." Rationale: IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet. Eating regular meals, drinking 8 to 10 cups of liquid a day, and chewing food slowly help to promote normal bowel function. Medication therapy depends on the main symptoms of IBS. Bulk-forming laxatives or antidiarrheal agents or other agents may be prescribed.
The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? A. "I should increase the fiber in my diet." B. "I will need to avoid caffeinated beverages." C. "I'm going to learn some stress reduction techniques." D. "I can have exacerbations and remissions with Crohn's disease."
A. "I should increase the fiber in my diet." Rationale: Crohn's disease is an inflammatory disease that can occur anywhere in the gastrointestinal tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If stress increases the symptoms of the disease, the client is taught stress management techniques and may require additional counseling. The client is taught to avoid gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber diet may be prescribed, especially during periods of exacerbation.
The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? A. "It will cause diaphoresis and diarrhea." B. "I have to monitor for hiccups and diarrhea." C. "It will be associated with constipation and fever." D. "I have to monitor for fatigue and abdominal pain."
A. "It will cause diaphoresis and diarrhea." Rationale: Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. The remaining options are not signs of dumping syndrome.
Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? A. "The medication will cause constipation." B. "I need to take the medication with meals." C. "I may have increased sensitivity to sunlight." D. "This medication should be taken as prescribed."
A. "The medication will cause constipation." Rationale: Sulfasalazine is an antiinflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.
The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan? A. Use 500 to 1000 mL of warm tap water. B. Suspend the irrigant 36 inches above the stoma. C. Insert the irrigation cone ½ inch into the stoma. D. If cramping occurs, open the irrigation clamp farther.
A. Use 500 to 1000 mL of warm tap water. Rationale: The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. A. Administer stool softeners as prescribed. B. Instruct the client to limit fluid intake to avoid urinary retention. C. Encourage a high-fiber diet to promote bowel movements without straining. D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. E. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding.
A. Administer stool softeners as prescribed. C. Encourage a high-fiber diet to promote bowel movements without straining. D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action should be the priority for this client? A. Assessment of vital signs B. Complete abdominal examination C. Thorough investigation of precipitating events D. Insertion of a nasogastric tube and Hematest of emesis
A. Assessment of vital signs Rationale: The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. A. Coffee B. Chocolate C. Peppermint D. Nonfat milk E. Fried chicken F. Scrambled eggs
A. Coffee B. Chocolate C. Peppermint E. Fried chicken Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? A. Dark red drainage B. Dark brown drainage C. Green-tinged drainage D. Light yellowish-brown drainage
A. Dark red drainage Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? A. Decreased diarrhea B. Decreased cramping C. Improved intestinal tone D. Elimination of peristalsis
A. Decreased diarrhea Rationale: Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication.
The nurse is providing discharge instructions for a client following a Roux-en-Y gastric bypass surgery 3 days ago. What will the nurse include in the instructions? Select all that apply. A. Do not drink fluids with meals. B. Avoid foods high in carbohydrates. C. Take an extended-release multivitamin daily. D. Maintain a clear liquid diet for about 6 weeks. E. Eat 6 small meals a day that are high in protein.
A. Do not drink fluids with meals. D. Maintain a clear liquid diet for about 6 weeks. E. Eat 6 small meals a day that are high in protein. Rationale: A Roux-en-Y gastric bypass is a combination of restrictive and malabsorptive surgery in which the size of the stomach is made much smaller and a large part of the small intestine (which absorbs food) is bypassed. Because the stomach is so small, clients are instructed to not drink fluids with meals because providers do not want them to fill up on less nutritional liquids before having food; to avoid foods high in carbohydrates because they are not as nutritional and tend to promote diarrhea and dumping syndrome; and to eat frequent, small meals that are high in protein. An extended-release vitamin will not be absorbed by the client since much of the small intestine is bypassed and food moves through quickly, and 6 weeks is too long a period to be on clear liquids. The typical bariatric surgery client is only on clear liquids for a few days and should then be on a high-protein diet.
The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply. A. Eat yogurt. B. Take loperamide to treat diarrhea. C. Use stress management techniques. D. Avoid foods such as cabbage and broccoli. E. Decrease fiber intake to less than 15 g/day.
A. Eat yogurt. B. Take loperamide to treat diarrhea. C. Use stress management techniques. D. Avoid foods such as cabbage and broccoli. Rationale: IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day.
The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? A. Encourage the client to ambulate. B. Position the client on the left side. C. Frequently irrigate the nasogastric tube (NG) with 30 mL saline. D. Discourage the use of the patient-controlled analgesia (PCA) machine.
A. Encourage the client to ambulate. Rationale: Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications.
The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively? A. Low fiber B. Low calorie C. High protein D. High carbohydrate
A. Low fiber Rationale: For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? A. Lying recumbent following meals B. Consuming small, frequent, bland meals C. Taking H2-receptor antagonist medication D. Raising the head of the bed on 6-inch (15 cm) blocks
A. Lying recumbent following meals Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax following meals and during sleep.
A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? A. NPO (nothing by mouth) status B. Ambulation at least 4 times daily C. Cholinergic medications to reduce pain D. Coughing and deep breathing every 2 hours
A. NPO (nothing by mouth) status Rationale: During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms, and increased intra-abdominal pressure (coughing and deep breathing) may precipitate an attack. Ambulation and cholinergics will increase peristalsis.
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply. A. Nuts B. Corn C. Liver D. Apples E. Lentils F. Bananas
A. Nuts C. Liver E. Lentils Rationale: Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.
The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply. A. Pull the tube back slightly. B. Instruct the client to breathe slowly. C. Assist the client to take sips of water. D. Continue to slowly advance the tube to the desired distance. E. Check the back of the pharynx using a tongue blade and flashlight.
A. Pull the tube back slightly. B. Instruct the client to breathe slowly. C. Assist the client to take sips of water.. E. Check the back of the pharynx using a tongue blade and flashlight. Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.
A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? A. Remove fluids from the meal tray. B. Give the client 2 large meals per day. C. Ask the client to sit up for 1 hour after eating. D. Provide concentrated, high-carbohydrate foods.
A. Remove fluids from the meal tray. Rationale: Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying.
A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation.
A. This is a normal, expected event. Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.
During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? A. Increase potassium in the diet. B. Include rice and bananas in the diet. C. Increase fluid and dietary fiber intake. D. Increase the intake of sugar-free products.
C. Increase fluid and dietary fiber intake. Rationale: Increase of fluid intake and dietary fiber will help change the consistency of the stool, making it easier to pass. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not assist in alleviating constipation.
The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which client statement indicates that the educational session was effective? A. "I should be sure to eat at least 1 cucumber every day." B. "Beet greens, parsley, or yogurt will help to control the colostomy odor." C. "I will need to increase my egg intake and try to eat ½ to 1 egg per day." D. "Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day."
B. "Beet greens, parsley, or yogurt will help to control the colostomy odor." Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.
The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? A. "I walk 1 to 2 miles every day." B. "I need to decrease fiber in my diet." C. "I have a bowel movement every other day." D. "I drink 6 to 8 glasses of water every day."
B. "I need to decrease fiber in my diet." Rationale: An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.
The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? A. "I need to lie down after eating." B. "I need to drink liquids with meals." C. "I need to avoid concentrated sweets." D. "I need to eat small meals 6 times daily."
B. "I need to drink liquids with meals." Rationale: The client with dumping syndrome should avoid drinking liquids with meals. The client should be placed on a high-protein, moderate-fat, high-calorie diet and should lie down after eating. The client should avoid concentrated sweets, and frequent small meals are encouraged.
A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client? A. A low-fat diet B. A low-fiber diet C. A high-protein diet D. A high-carbohydrate diet
B. A low-fiber diet Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record? A. Apply a cold pack to the abdomen. B. Administer 30 mL of milk of magnesia (MOM). C. Maintain nothing by mouth (nil per os [NPO]) status. D. Initiate an intravenous (IV) line for the administration of IV fluids.
B. Administer 30 mL of milk of magnesia (MOM). Rationale: Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.
A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? A. On arising B. After meals C. On an empty stomach D. 30 minutes before meals
B. After meals Rationale: Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation.
The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. A. Antidiarrheal B. Antimicrobial C. Corticosteroid D. Aminosalicylate E. Biological therapy F. Immunosuppressant
B. Antimicrobial C. Corticosteroid D. Aminosalicylate E. Biological therapy F. Immunosuppressant Rationale: Pharmacological treatment for IBD aims to decrease the inflammation to induce and then maintain a remission. Five major classes of medications used to treat IBD are antimicrobials, corticosteroids, aminosalicylates, biological and targeted therapy, and immunosuppressants. Medications are chosen based on the location and severity of inflammation. Depending on the severity of the disease, clients are treated with either a "step-up" or "step-down" approach. The step-up approach uses less toxic therapies (e.g., aminosalicylates and antimicrobials) first, and more toxic medications (e.g., biological and targeted therapy) are started when initial therapies do not work. The step-down approach uses biological and targeted therapy first. Option 1, antidiarrheals, is incorrect. Although an antidiarrheal may be used to treat the symptoms of IBD, it does not treat the disease (the inflammation) or induce remission. In addition, antidiarrheals should be used cautiously in IBD because of the danger of toxic megacolon (colonic dilation greater than 5 cm).
A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? A. Folate B. Biscodyl C. Ferrous sulfate D. Cyanocobalamin
B. Biscodyl Rationale: The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. Laxatives will compound the potential risk for the client. These clients are at risk for deficiencies of folate, iron, and cyanocobalamin and should receive them as supplements if necessary.
The nurse is caring for a client prescribed enteral feeding via a newly inserted nasogastric (NG) tube. Before initiating the enteral feeding, the nurse should perform which action first? A. Warm the feeding to 103°F (39.4°C). B. Confirm NG placement by x-ray study. C. Make sure the continuous enteral feeding tubing is primed. D. Position the head of the client's bed to 30 degrees or greater.
B. Confirm NG placement by x-ray study. Rationale: Before initiating enteral feedings via a newly inserted NG tube, the placement of the tube is confirmed by x-ray. If the tube is not in the stomach, the client is at risk for aspiration. Formulas are administered at room temperature, not at 103°F. To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Although an important action, it is not the priority. Priming the enteral feeding tube is important prior to initiating the feedings; however, it is not the priority action.
The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? A. Rice B. Corn C. Broiled chicken D. Cream of wheat
B. Corn Rationale: The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? A. Leukopenia with a shift to the left B. Leukocytosis with a shift to the left C. Leukopenia with a shift to the right D. Leukocytosis with a shift to the right
B. Leukocytosis with a shift to the left Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appenditis.
After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? A. Stroke B. Pernicious anemia C. Bacterial meningitis D. Peripheral arterial disease
B. Pernicious anemia Rationale: Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent.
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? A. Stoma is beefy red and shiny B. Purple discoloration of the stoma C. Skin excoriation around the stoma D. Semi-formed stool noted in the ostomy pouch
B. Purple discoloration of the stoma Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semi-formed stool is a normal finding.
The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome? A. Diarrhea, chills, and hiccups B. Weakness, diaphoresis, and diarrhea C. Fever, constipation, and rectal bleeding D. Abdominal pain, elevated temperature, and weakness
B. Weakness, diaphoresis, and diarrhea Rationale: Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? A. Digoxin B. Furosemide C. Indomethacin D. Propranolol hydrochloride
C. Indomethacin Rationale: Indomethacin is a nonsteroidal antiinflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.
The nurse has given postprocedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching? A. "It is normal to feel gassy or bloated after the procedure." B. "The abdominal muscles may be tender from the procedure." C. "It is all right to drive once I've been home for an hour or so." D. "Intake should be light at first and then progress to regular intake."
C. "It is all right to drive once I've been home for an hour or so." Rationale: The client should not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client should resume intake slowly and progress as tolerated.
A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? A. Ibuprofen B. Indomethacin C. Acetaminophen D. Naproxen sodium
C. Acetaminophen Analgesics, such as acetaminophen, are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal antiinflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they should be avoided in clients with gastritis.
A client with a gastric ulcer is prescribed both magnesium hydroxide and cimetidine twice daily. How should the nurse schedule the medications for administration? A. Drink 8 ounces of water between taking each medication. B. Administer the cimetidine and magnesium hydroxide at the same time twice daily. C. Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. D. Collaborate with the health care provider (HCP), as the client should not be receiving both medications.
C. Administer each dose of cimetidine 1 hour prior to the administration of magnesium hydroxide. Antacids, such as magnesium hydroxide, can decrease absorption of cimetidine. At least 1 hour should separate administration of an antacid and cimetidine. The remaining options are incorrect.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? A. Call the surgeon to report the problem. B. Reposition the NG tube to the proper location. C. Check the suction device to make sure it is working. D. Irrigate the NG tube with saline to remove the obstruction.
C. Check the suction device to make sure it is working. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy.
The nurse is caring for a client postoperatively after creation of a colostomy. What is an appropriate potential client problem? A. Fear B. Sexual dysfunction C. Disturbed body image D. Imbalanced nutrition: more than body requirements
C. Disturbed body image Rationale: Disturbed body image for a client who is postoperative after creation of a colostomy relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). There are no data in the question to support sexual dysfunction or fear. Imbalanced nutrition: less (not more) than body requirements is the more likely client problem.
The nurse is preparing to administer an intermittent enteral feeding though a nasogastric (NG) tube. Which priority assessment should the nurse perform? A. Observe for digestion of formula. B. Assess fluid and electrolyte status. C. Evaluate absorption of the last feeding. D. Evaluate percussion tone of the stomach.
C. Evaluate absorption of the last feeding. Rationale: All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration. The remaining options do not relate to the purpose of assessing residual.
The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? A. Fleet enema B. Fecal disimpaction C. Glycerin suppository D. Soap solution enema (SSE)
C. Glycerin suppository Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client.
The nurse is caring for a client who is receiving bolus feedings via a nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat for sleep. The nurse understands that which is the appropriate position for this client at this time? A. Head of bed flat, with the client supine for 60 minutes B. Head of bed flat, with the client in the supine position for at least 30 minutes C. Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes D. Head of bed in a semi Fowler's position, with the client in the left lateral position for 60 minutes
C. Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for 60 minutes after a bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying and thus prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding.
The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications are not a part of the treatment plan because of its irritating effects on the lining of the gastrointestinal tract? A. Nizatidine B. Sucralfate C. Ibuprofen D. Omeprazole
C. Ibuprofen Rationale: Ibuprofen is a nonsteroidal antiinflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? A. Leg exercises B. Early ambulation C. Irrigating the nasogastric tube D. Coughing and deep-breathing exercises
C. Irrigating the nasogastric tube Rationale: In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? A. Ambulate following a meal. B. Eat high-carbohydrate foods. C. Limit the fluids taken with meals. D. Sit in a high Fowler's position during meals.
C. Limit the fluids taken with meals. Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease? A. Blood in the stool B. Chalky gray stool C. Loose, watery stool D. Dry, hard, constipated stool
C. Loose, watery stool Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than 4 or 5 stools daily. Over time, the episodes of diarrhea increase in frequency, duration, and severity. Options 1, 2, and 4 are not characteristics of the stool in Crohn's disease.
The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client? A. Maintain a high-carbohydrate diet. B. Increase fluid intake, particularly at mealtime. C. Maintain a low Fowler's position while eating. D. Ambulate for at least 30 minutes following each meal.
C. Maintain a low Fowler's position while eating. Rationale: The client at risk for dumping syndrome should be instructed to maintain a low Fowler's position while eating and lie down for at least 30 minutes after eating. The client also should be told that small, frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome.
The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? A. Enteral feedings B. Fluid restrictions C. Oral corticosteroids D. Activity restrictions
C. Oral corticosteroids Rationale: Crohn's disease is a form of inflammatory bowel disease that is a chronic inflammation of the gastrointestinal (GI) tract. It is characterized by periods of remission interspersed with periods of exacerbation. Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which sign(s)/symptom(s) of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain relieved by food intake D. Pain radiating down the right arm
C. Pain relieved by food intake Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain that is relieved by food intake D. Pain that radiates down the right arm
C. Pain that is relieved by food intake Rationale: The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the midepigastric area. It does not radiate down the right arm. The client with duodenal ulcer does not usually experience weight loss or nausea and vomiting; these symptoms are more typical in the client with a gastric ulcer.
The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? A. Hypotension B. Bloody diarrhea C. Rebound tenderness D. A hemoglobin level of 12 mg/dL (120 mmol/L)
C. Rebound tenderness Rationale: Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the HCP.
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the health care provider (HCP). The nurse should contact the HCP to question which prescription if noted in the client's record? A. Maintain a semi Fowler's position. B. Maintain on NPO (nothing by mouth) status. C.Apply a heating pad to the lower abdomen for comfort. D. Initiate an intravenous (IV) line with the administration of IV fluids.
C.Apply a heating pad to the lower abdomen for comfort. Rationale: Appendicitis should be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi Fowler's position is maintained for comfort. The client would be on NPO status and given IV fluids in preparation for possible surgery. Heat should never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation.
A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? A. "I know I can massage my abdomen." B. "I will continue using antispasmodic medication." C. "One of the best things I can do is use relaxation techniques." D. "The best position for me is to lie supine with my legs straight."
D. "The best position for me is to lie supine with my legs straight." Rationale: Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.
The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period? A. "When I can tolerate food without vomiting." B. "When my gastrointestinal system is healed enough." C. "When my health care provider says the tube can come out." D. "When my bowels begin to function again, and I begin to pass gas."
D. "When my bowels begin to function again, and I begin to pass gas." Rationale: NG tubes are discontinued when normal function returns to the gastrointestinal (GI) tract. Food would not be administered unless bowel function returns. The tube will be removed before GI healing. Although the health care provider (HCP) determines when the NG tube will be removed, it does not determine effectiveness of teaching and the need for the NG tube.
A client has a large, deep duodenal ulcer diagnosed by endoscopy. Which sign or symptom indicative of a complication should the nurse look for during the client's postprocedure assessment? A. Bradycardia B. Nausea and vomiting C. Numbness in the legs D. A rigid, boardlike abdomen
D. A rigid, boardlike abdomen Rationale: The client with a large, deep duodenal ulcer is at risk for perforation of the ulcer. If this occurs, the client will experience sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which then becomes rigid and boardlike. Tachycardia, not bradycardia, may occur as hypovolemic shock develops. Nausea and vomiting may not occur if the pyloric sphincter is intact. Numbness in the legs is not an associated finding.
The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observation if this is present? A. A sunken and hidden stoma B. A narrow and flattened stoma C. A stoma that is dusky or bluish D. A stoma that is elongated with a swollen appearance
D. A stoma that is elongated with a swollen appearance Rationale: A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance of the stoma. A retracted stoma is characterized by sinking of the stoma. A stoma with a narrow opening is described as being stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.
A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? A. Carrots and ranch dip B. Whole-grain cereal and milk C. A cup of popcorn and a cola drink D. Applesauce and a graham cracker
D. Applesauce and a graham cracker Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.
A client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure? A. Assessing pulses B. Monitoring urine output C. Monitoring for rectal bleeding D. Assessing for the presence of the gag reflex
D. Assessing for the presence of the gag reflex Rationale: Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure.
A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? A. Discontinue the enema. B. Reassure the client, and continue the flow. C. Raise the enema bag so that the solution can be completed quickly. D. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
D. Clamp the tubing for 30 seconds, and restart the flow at a slower rate. Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect.
The nurse should instruct a client with an ileostomy to include which action as part of essential care of the stoma? A. Massage the area below the stoma. B. Take in high-fiber foods such as nuts. C. Limit fluid intake to prevent diarrhea. D. Cleanse the peristomal skin meticulously.
D. Cleanse the peristomal skin meticulously. Rationale: The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by high-fiber foods. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. Fluid intake should be at least 6 to 8 glasses of water per day to prevent dehydration.
The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? A. Hypercalcemia B. Hypernatremia C. Frothy, fatty stools D. Decreased hemoglobin
D. Decreased hemoglobin Rationale: Ulcerative colitis is an inflammatory disease of the large colon. Findings associated with ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia (not hypercalcemia). Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).
The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriate based on this assessment? A. Apply ice to the stoma site. B. Apply pressure to the stoma site. C. Notify the health care provider (HCP). D. Document the amount and characteristics of the drainage.
D. Document the amount and characteristics of the drainage. Rationale: During the first 24 to 72 hours following surgery, mucus and serosanguineous drainage are expected from the stoma. Applying ice or pressure to the stoma site are inappropriate actions. Notifying the HCP is unnecessary because this is an expected finding.
A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which item mentioned by the client is most likely to be responsible for the exacerbation? A. Sleeping 8 to 10 hours a night B. Ability to work at home periodically C. Eating 5 or 6 small meals per day D. Frequent need to work overtime on short notice
D. Frequent need to work overtime on short notice Rationale: Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. Of the items listed, the frequent need to work overtime on short notice is potentially the most stressful because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and proper dietary pattern (options 1 and 3) should alleviate symptoms, not worsen them.
The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? A. Colectomy B. Appendectomy C. Ascending colostomy D. Small bowel resection
D. Small bowel resection Rationale: The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options.
The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? A. Sufficiently low water content in the stool B. Low intestinal roughage that promotes easier digestion C. Constriction of the anal sphincter based on voluntary control D. Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord
D. Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord Rationale: The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.
The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? A. Recently retired from a job B. Significant other has a gastric ulcer C. Occasionally drinks 1 cup of coffee in the morning D. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis
D. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis Rationale: Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, NSAIDs, caffeine, alcohol, and stress. When an NSAID is taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn's disease, Zollinger-Ellison syndrome, and hepatic and biliary disease also can increase the risk for PUD by changing the amount of gastric and biliary acids produced. Recent retirement should decrease stress levels rather than increase them. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. A significant other is not a first-degree relative; therefore, no genetic connection is noted in this relationship. Although caffeinated drinks are a known risk factor for PUD, the option states that the client drinks 1 cup of coffee occasionally.
The nurse is caring for a client with pernicious anemia. Which prescription by the health care provider (HCP) should the nurse anticipate? A. Iron B. Folic acid C. Vitamin B6 D. Vitamin B12
D. Vitamin B12 Rationale: Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of administration of high doses of oral vitamin B12. Monthly injections of vitamin B12 can also be administered but are less comfortable when compared to oral administration. Thiamine is most often prescribed for the client with alcoholism, folic acid is prescribed for folic acid deficiency, and vitamin B6 is ordered when there is pyridoxine deficiency.
The nurse should anticipate that the health care provider (HCP) will prescribe which treatment for a client with pernicious anemia? A. Oral iron tablets B. Blood transfusions C. Gastric tube feedings D. Vitamin B12 injections
D. Vitamin B12 injections Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption.
