NCLEX 10000 gastro disorders
Which outcome is expected for a client who has undergone surgical repair of an inguinal hernia?
the client will verbalize understanding of instructions to avoid lifting for 2-6 weeks
The nurse enters the room of an adult female who has just returned from the operating room after undergoing an incisional cholecystectomy. Which finding requires prompt action by the nurse?
the clients knee watch is elevated
A nurse is caring for a client who had gastric bypass surgery two days ago. Which assessment finding requires immediate intervention?
the clients right lower leg is red swollen and warm to touch
The nurse prepares to administer promethazine 35 mg IM as prescribed PRN for a client with cholecystitis who has nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place.
1.4
A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/hour. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number.
25
A client has 4000 mL removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record you answer in whole numbers.
4
The nurse has a prescription to administer sulfasalazine 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? Record your answer using a whole number.
4
he nurse has a prescription to administer sulfasalazine 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer? Record your answer using a whole number.
4
A nurse teaches a client experiencing heartburn to take 1.5 oz of aluminum hydroxide when symptoms appear. How many milliliters should the client take? Record your answer using a whole number.
45
Amoxicillin trihydrate 300 mg PO has been prescribed for a client with an oral infection. The medication is available in a liquid suspension that is available as 250 mg/5 mL. How many milliliters should the nurse administer? Record your answer using a whole number.
6
The nurse has an order to administer 2 oz of lactulose to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer? Record your answer using a whole number.
60
A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?
Cullen's sign
An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?
I can make a small pin hole in the bag to let the gas out
A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult?
I didn't eat anything I shouldn't have I just ate roast beef on rye bread
A client with constipation takes psyllium granules as one rounded teaspoon mixed in fruit juice three times daily. Which of the following statements by the client indicates that further teaching is required?
I will need to take the medication for 4 weeks
A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client's room to review discharge instructions with the client when he tells the nurse that he wants help to quit drinking. How should the nurse respond?
I'll notify your physician and call the social worker so she can discuss treatment
The nurse is checking the client's chart for possible contraindications, before administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse should hold the meperidine when she sees an order for what type of drug?
MOA inhibitor
Which is an expected outcome for a client with peptic ulcer disease? The client will:
explain the rationale for eliminating alcohol from the diet
The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to the use of PPE?
PPE should be used when you risk exposure
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
SaO2 of 89%
In caring for the client with hepatitis B, which situation would expose the nurse to the virus?
a blood splash into the nurses eyes
When a client has an acute attack of diverticulitis, the nurse should first:
assess the client for signs of peritonitis
After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first
a client with hepatitis whose pulse was 84 bmp and regular
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis?
a demanding and stressful job
A nurse is assessing a client who has a history of a bleeding peptic ulcer. Which of the following assessments should the nurse report immediately?
abd distention cool clammy skin week thready pulse
What observation should the nurse instruct the client with an ileostomy to report immediately?
absence of drainage from the ileostomy for 6 or more hours
A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes?
acetaminophen
A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?
acute pain
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
acute pain related to biliary spasms
Which outcome is appropriate for the client with hepatitis B? The client will:
adhere to measures to prevent the spread of infection to others
Which skin preparation would be best to apply around the client's colostomy?
adhesive skin barrier
A client had a colon resection yesterday. The client's hemoglobin was 14.1 g/dL yesterday and today it is 7.2 g/dl. The client's oxygen saturation is 87%. After reviewing the chart (see chart) and notifying the health care provider (HCP), the nurse should first:
administer oxygen at 2 liters per min
Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?
administering pain meds
A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which measure should be included in the client's care once the Cantor tube has passed into the duodenum?
advance the tube 2 to 4 inches at specified times
The nurse is caring for a 70-year-old male client after a colectomy. The client has received chemotherapy prior to surgery and has hypertension and diabetes mellitus. Which factors put this client at risk for sepsis? Select all that apply.
age abd surgery diabetes melitus
Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery?
age 30 with poorly controlled diabetes
A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
albumin
A nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
alcohol abuse and smoking
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on his/her left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will:
allow proper visualization of the large intestine
A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. The nurse knows that palpating the abdomen first would:
alter abdominal sounds from baseline
The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?
an orange, raisin bran and milk and wheat toast with butter
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
anorexia nausea and vomiting
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which of the following problems is associated with cirrhosis of the liver?
ascites related to portal hypertension
A client is scheduled for oral cholecystography. Prior to the test, the nurse should:
ask the client about possible allergies to iodine or shellfish
While changing the client's colostomy bag and dressing, the nurse determines that the client is ready to participate in self-care when the client:
asks about the supplies used during the dressing change
The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was prescribed for the day. The nurse should:
asses the infusion system, not the clients condition and notify the health care provider
The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was prescribed for the day. The nurse should:
assess the infusion system note the clients condition and notify the HCP
A nurse is delegating activities to unlicensed assistive personnel (UAP). Which activities can be appropriately delegated? Select all that apply.
assist client with oral care measure and record intake
A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema? Select all that apply.
assist the client lubricate be sure to keep the solution
A client is to take one daily dose of ranitidine at home to treat a peptic ulcer. The client understands proper drug administration of ranitidine when the client will take the drug:
at bedtime
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.6 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?
atropine decreases salivation and gastric secretions
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?
autonomy
A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and famotidine. Before the client is discharged, the nurse should provide which instruction?
avoid aspirin and products that contain aspirin
The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. The nurse should teach the client to:
avoid lifting items weighing more than 5 lb
A physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine?
before the pain becomes severe
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process?
blood is not able to flow readily though the liver now and the liver cannot make protein
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?
blood supply to the stoma has been interrupted
A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for:
bloody, diarrheal stools
In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful?
body mechanics used in lifting
The nurse determines that a client's abdominal wound has eviscerated. What should the nurse do first?
cover the wound with sterile saline moistened dressing
As a nurse completes the admission assessment of a client admitted for gastric bypass surgery, the client states, "Finally! I'll be thin and able to eat without much concern." Which statement by the nurse would be most appropriate?
can you tell me tour best understanding of the procedure
Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tu
change tube feeding administration set at least every 24 hours
The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first?
check the function of the suction equipment
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:
cirrhosis
When preparing a client for a scheduled colonoscopy, the nurse should tell the client that this procedure will involve:
cleansing the bowel with laxatives or enemas
A nurse is caring for a client who just had an appendectomy. The client is receiving opioid analgesics routinely for pain. The nurse should focus her follow-up assessment on which complication?
constipation
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
continue to take antacids even of your symptoms subside
A client's abdominal incision eviscerates. The nurse should first:
cover the incision with a dressing moistened with sterile normal saline
client's abdominal incision eviscerates. The nurse should first:
cover the incision with a dressing moistened with sterile normal saline
On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half of the incision has torn apart. What should the nurse do first?
cover the wound with a sterile dressing moistened with normal saline
A client who had a splenectomy yesterday has a nasogastric (NG) tube. The expected outcome of using the NG tube is to:
decrease abd distension
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin. The rationale for neomycin use in this client is to:
decrease the intestinal bacterial count
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing?
decreased mental status
Which are the important considerations by the nurse before administering feedings to a client through a nasogastric tube? Select all that apply.
determine placement measure the pH
A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing:
difficulty coping
The nurse is caring for a client one day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5° F (38.6° C), blood pressure 92/36 mm Hg (MAP 55), heart rate 114 with SpO2 of 88% on oxygen at 2L/min/nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?
draw blood cultures
A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan?
discussing collaborative goals and involving the client in identifying
Which instruction should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
do not lie down for 2 hours after eating
The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)?
elevated PT/INR
The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate?
eat a soft bland diet
A nurse is caring for a client following gastric bypass surgery. At the six week appointment, the client reports symptoms of nausea, abdominal pain and cramping following meals and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply.
eat small reduce high refer client to dietician
Which dietary measure would be useful in preventing esophageal reflux?
eating small frequent meals
Which laboratory finding is expected when a client has diverticulitis?
elevated white blood cell count
A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow?
encourage plenty of fluids
A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?
encourage the client to ambulate at least 3 times per day
During the assessment of a client's mouth, the nurse notes the absence of saliva. The client reports having pain behind the ear. The client has been nothing-by-mouth (NPO) for several days, but now can have liquids. The nurse should:
encourage the client to suck on a hard candy
Cimetidine may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following?
esophagitis
At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
evaluate the tube for potency
After abdominal surgery, a client is reluctant to turn in bed. The nurse should:
explain the importance of turning to the client
A client has been taking prescribed aspirin in large doses and reports having stomach irritation, sometimes with vomiting. Which food or beverage noted from the client's diet history should the nurse suggest the client avoid?
glass of wine
The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has:
had a tattoo
The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client:
has a known hx of sexually transmitted disease
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
has your partner had recent forceful vomiting
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock?
heart rate above 100 beats/min
The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which symptom?
heatburn
On 1/16 at 0800 the nurse is caring for a client with acute pancreatitis and reviewing progress notes as listed. (See figure.) Which finding indicates that the desired outcome of the transfusion is obtained at this time?
hemoglobin is 12
A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 101.1° F (38.4° C); pulse 114 bpm; respirations 22/min; blood pressure 142/90 mm Hg. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the health care provider for the client to receive:
hydromorphone IV
A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?
hypokalemia
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
hypokalemia
The nurse is aware that client teaching has been effective about the potential toxic reactions to a vitamin B12 injection by the following statement. Select all that apply.
i may be asked to remain in the clinic for 30 min i will need to check with my physician vit B12 is generally free
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
i need to use laxatives reg
Which statement indicates that the client with a peptic ulcer understands the dietary modifications to follow at home?
i should avoid alcohol and caffeine
Which statement indicates that the client understands the home care of a colostomy?
i should be able to establish a reg pattern
The nurse is evaluating the lifestyle modifications a client has made to prevent gastroesophageal reflux. Which statement indicates that the client understands how to prevent reflux?
i try to eat smaller amounts of food more often throughout the day
A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholycystectomy later in the day, the client asks the nurse why the procedure is needed. Which of the following is the appropriate response by the nurse?
i will ask the surgeon
A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch?
i will empty my pouch when it is about one third full
Which statement indicates the client understands the lifestyle modifications required when managing ulcerative colitis?
i will have to stop smoking
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
ill eat frequent, small bland meals that are high in fiber
A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse her concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best?
im not at liberty
At the beginning of the shift, the nurse is assigned a client with an ascending colostomy. Which picture identifies the correct placement where the nurse will assess the stoma?
image D
A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?
increased serum amylase and lipase levels
A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client:
increases food intake and tolerance gradually
A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?
ineffective breathing pattern
A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task?
initiating IV therapy as ordered
A client has been taking aluminum hydroxide 30 ml six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that the most likely cause of the client's constipation is because the client:
is experiencing an adverse effect of the aluminum hydroxide
A client diagnosed with ulcerative colitis also experiences obsessive compulsive anxiety disorder (OCD). In helping the client understand her illness, the nurse should respond with which statement?
it is possible that your desire to have everything be perfect has caused stress
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an IV infusion of dextrose 5% in half-normal saline solution at 120 mL/h. After 3 days of this regimen, the nurse should observe the client for which adverse metabolic condition?
ketosis
The correct procedure for auscultating the client's abdomen for bowel sounds is to:
listen for 5 min in all four quadrants to confirm absence of bowel sounds
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?
liver
A nurse is caring for a client after a hemorrhoidectomy. Which of the following orders would the nurse question on the medical record?
low fiber diet
The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is:
lying down
A client has massive bleeding from esophageal varices. In what order from first to last should the nurse and care team provide care for this client? All options must be used.
maintain control replace relieve
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate?
maintain a high carb low fat diet
The nurse monitors IV replacement therapy for a client with a nasogastric (NG) tube attached to low suction in order to:
maintain fluid and electrolyte balance
A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time?
manage the pain
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?
metabolic acidosis
Following a subtotal gastrectomy, a client has a nasogastric (NG) tube connected to low suction. The nurse should:
monitor the client for N/V and and distention
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?
monitoring the clients weight every day
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?
nothing by mouth
A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should:
notify the physician that the client doesn't understand the procedure
When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just not sure." The nurse should:
notify the surgeon of the clients expressed lack of understanding
Postoperative nursing care for a client after an appendectomy should include:
noting the first bowel movement after surgery
The nurse has been teaching the client about maintaining a high-fiber diet. The client's selection of which breakfast menu indicates an understanding of the instructions?
oatmeal milk grapefruit wedges and bran muffin
After gastric resection surgery, which signs alert the nurse to the development of a leaking anastomosis?
pain, fever, and abd rigidity
A client has been admitted to the emergency department with severe mid-epigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart below, the nurse would anticipate preparing for which diagnosis?
pancreatitis
A client with diverticular disease is receiving psyllium hydrophilic mucilloid. The drug has been effective when the client:
passess stool without cramping
A client with acute pancreatitis has a blood pressure of 88/40 mm Hg, heart rate of 128 bpm, respirations of 28/min, and Grey Turner's sign. What prescription should the nurse implement first?
place an intravenous line
The nurse is caring for a client that has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. What is the nurse's first response?
place saline soaked sterile dressings on the wound
When administering intermittent enteral feeding to an unconscious client, the nurse should:
place the client in a semi fowlers position
When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which clinical findings?
poor skin turgor
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
positioning the client on the side with the knees flexed
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl (11.32 mmol/L); blood urea nitrogen (BUN): 12 mg/dl (0.67 mmol/L); Creatinine: 0.9 mg/dl (0.05 mmol/L); Sodium: 136 mEq/L (136 mmol/L); Potassium: 2.2 mEq/L (2.2 mmol/L); Chloride: 99 mEq/L (99 mmol/L); CO2: 33 mEq/L (33 mmol/L). Which result should the nurse identify as critical and report immediately?
potassium
Which client requires immediate nursing intervention? The client who:
presents with a rigid, boardlike abd
When planning care for a client with hepatitis A, the nurse should review labororatory reports for which laboratory value?
prolonged prothrombin time
A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to:
promote drainage of wound exudates
A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first?
provide parenteral rehydration therapy
The nurse administers fat emulsion solution during TPN as prescribed based on the understanding that this type of solution
provides essential fatty acids
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
purpura and petechiae
The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9° F (37.2° C), heart rate 118 bpm, shallow respirations 26/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. The nurse should first:
raise the head of the bed
A nurse is caring for a client who has had paraplegia for 6 years. The client is admitted with a bleeding peptic ulcer. What would be a priority teaching concern for the nurse?
recommending foods included in a bland diet
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
teach the client to use a folded blanket or pillow to splint the incision
A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. The nurse should:
report the finding to the HCP
A registered nurse should assign a nursing assistant to care for a client with inflammatory bowel disease who:
requires assistance with ambulation
A nurse is giving instructions to a client with a new colostomy. The client states, "I am so tired today; I just cannot think." The nurse should:
reschedule the appt at the time when the client is rested
Immediately following endoscopy of the upper gastrointestinal tract, it is most important for the nurse to assess for:
return of the gag reflex
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
rigid abd wall
After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet?
roast beef
After being admitted to the emergency department for severe lower right quadrant pain, a child states that the pain has suddenly resolved. Which of the following would the nurse suspect?
ruptured appendix
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on the need for:
safe sexual practices
College freshmen are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on the need for:
safe sexual practices
The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has:
severe abd pain
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find:
severe and pain with direct palpation or rebound tenderness
Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider (HCP), the nurse should make which recommendation?
shall I collect and send a urine sample for culture and sensitivity
Which position would be best for the client in the early postoperative period after a hemorrhoidectomy?
side-lying
A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the:
small intestine
The client is to take nothing by mouth after 0400. The nurse recognizes that the client has deficient knowledge when he states that he:
smoked a cigarette at 0600
Two weeks before a client is scheduled for an ileostomy, the nurse should instruct the client to:
stop taking drugs that will interfere with clotting
The nurse irrigates a client's colostomy. If the client has abdominal cramping after receiving about 150 mL of solution during the colostomy irrigation, the nurse should:
stop the flow of solution
The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. The nurse should first:
stop the flow of solution
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
take a laxative
The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication?
take it with a full glass of water
In the early postoperative period, the nurse notes a bright red, 3" × 5" (7.6 cm x 12.7 cm) area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
take the clients vital signs
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which sign?
tarry stools
The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?
temp stop the infusion and have the client take deep breaths
A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?
test all stools for occult blood
A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid?
the action occurs in the stomach by increasing the pH of the stomach contents
When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?
the client assess flatus
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
the client is free from esophagitis and achalasia
Which indicates the client with ulcerative colitis has attained an expected outcome of nursing care?
the client maintains an ideal body weight
The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?
the client may be developing hypocalcemia
When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?
the client passes flatus
The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse?
the feeding that is infusing has been hanging for 8 hours
After teaching the parents of a child with lactose intolerance about the disorder, the nurse determines that the teaching was effective when the mother used which statement to describe the condition?
the lack of an enzyme to break down lactose
A graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?
the newly admitted client with acute and pain
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
the operative incision is near the diaphragm
After a nasogastric (NG) tube has been inserted, the nurse can most accurately determine that the tube is in the proper place when:
the pH of the aspirated fluid is measured
A 36-year-old female client has been diagnosed with hemorrhoids. Which factor in the client's history would most likely be a primary cause of her hemorrhoids?
three vaginal delivery preg
While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist?
timely administration of breathing treatments
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
to keep gastric pH at 3.0 to 3.5
A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of which of the following would be significant to this client's diagnosis?
ulcerative colitis
Which nursing recommendation is most appropriate for a client to decrease discomfort from hemorrhoids?
use warm sitz baths
Which is an appropriate nursing goal for the client who has ulcerative colitis? The
verbalizes the importance of small frequent meals
Which is an appropriate nursing goal for the client who has ulcerative colitis? The client:
verbalizes the importance of small frequesnt feedings
When giving a client a tube feeding, the nurse should:
verify position of the tube before beginning feeding
A nurse is caring for a client with symptoms of epigastric pain. When teaching the action of gastric contents related to functioning of the body, which actions occur in the stomach? Select all that apply.
vit B12 absorp breaking down food fibers killing activating the enzyme
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy. Which of the following vitamins would be affected by this?
vit k
Which finding is normal for a client during the icteric phase of hepatitis A?
yellowed sclera
