NURS250 chapter 12
The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for greatest concern? 1. "I'm very constipated and have been straining during bowel movements." 2. "I can't button my pants anymore because my belly is so swollen." 3. "I have a tight sensation in my lower legs when I forget to put my feet up." 4. "When I sleep, I have to sit in a recliner so that I can breathe more easily."
1. "I'm very constipated and have been straining during bowel movements." potential for sudden rupture of fragile blood vessels with massive hemorrhage because straining increases thoracic or abdominal pressure.
The client needs diagnostic testing to confirm symptoms of peptic ulcer disease (PUD), and the health care provider tells the nurse that the client prefers noninvasive methods. Which brochure is the nurse most likely to prepare for the client? 1. "Three Simple Ways to Detect H. pylori Using Your Blood, Breath, or Stool." 2. "How Your Doctor Uses a Chest and Abdomen X-ray Series to Detect PUD." 3. "Esophagogastroduodenoscopy: The Major Diagnostic Test for PUD." 4. "Common Questions and Answers About Nuclear Medicine Scans."
1. "Three Simple Ways to Detect H. pylori Using Your Blood, Breath, or Stool." H. pylori is frequently associated with PUD, and the organism can be detected through breath, blood, or stool.
A client underwent an exploratory laparotomy 2 days ago. The health care provider (HCP) should be called immediately for which physical assessment finding? 1. Abdominal distention and rigidity 2. Displacement of the nasogastric (NG) tube 3. Absent or hypoactive bowel sounds 4. Nausea and occasional vomiting
1. Abdominal distention and rigidity Distention and rigidity can signal hemorrhage or peritonitis.
The nurse hears in hand-off report that, 1 hour ago, the health care provider requested that the client be given the maximum dose of magnesium hydroxide. Which instruction is the nurse most likely to give to unlicensed assistive personnel? 1. Client will frequently need assistance to the bathroom for bowel evacuation. 2. Client may experience some dizziness when ambulating or changing position. 3. Client is frequently vomiting and may need linen and gown changes. 4. Client needs to be encouraged and assisted to eat and drink as much as possible.
1. Client will frequently need assistance to the bathroom for bowel evacuation. The maximum dose of magnesium hydroxide is given for bowel evacuation and cleansing. It is expected that the medication should have effect within 2 to 6 hours.
The nurse is preparing to administer total parenteral nutrition (TPN) through a central line. Place the following steps for administration in the correct order. - Thread the IV tubing through an infusion pump. - Check the solution for cloudiness or turbidity. - Connect the tubing to the central line, using aseptic technique. - Select and flush the correct tubing and filter. - Set the infusion pump at the prescribed rate. - Confirm the order for TPN before administration.
1. Confirm the order for TPN before administration. 2. Check the solution for cloudiness or turbidity. 3. Select and flush the correct tubing and filter. 4. Thread the IV tubing through an infusion pump. 5. Connect the tubing to the central line, using aseptic technique. 6. Set the infusion pump at the prescribed rate.
Place the steps for performing colostomy care in the correct order. - Fit the pouch snugly around the stoma. - Assess the color and appearance of the stoma. - Wash the skin with mild soap and rinse with warm water. - Apply a skin barrier to protect the peristomal skin. - Dry the skin carefully. - Don a pair of clean gloves and remove the old pouch.
1. Don a pair of clean gloves and remove the old pouch. 2. Assess the color and appearance of the stoma. 3. Wash the skin with mild soap and rinse with warm water. 4. Dry the skin carefully. 5. Apply a skin barrier to protect the peristomal skin. 6. Fit the pouch snugly around the stoma.
The nurse is teaching the client and family how to perform colostomy irrigation. Place the following information in the correct order. - Hang the container at about shoulder height. - Allow solution to flow slowly and steadily for 5 to 10 minutes. - Don clean gloves and put 500 to 1000 mL of lukewarm water in the container. - Lubricate the stoma cone and gently insert the tubing tip into the stoma. - Clean, rinse, and dry the skin, and apply a new drainage pouch. - Allow 15 to 20 minutes for initial evacuation; then the client should walk for 30 to 45 minutes for secondary evacuation.
1. Don clean gloves and put 500 to 1000 mL of lukewarm water in the container. 2. Hang the container at about shoulder height. 3. Lubricate the stoma cone and gently insert the tubing tip into the stoma. 4. Allow solution to flow slowly and steadily for 5 to 10 minutes 5. Allow 15 to 20 minutes for initial evacuation; then the client should walk for 30 to 45 minutes for secondary evacuation. 6. Clean, rinse, and dry the skin, and apply a new drainage pouch.
The nurse is providing the immediate postoperative care for a client who had fundoplication to reinforce the lower esophageal sphincter for the purpose of a hiatal hernia repair. What is the priority action for the care of this client? 1. Elevate the head of the bed at least 30 degrees. 2. Assess the nasogastric tube for yellowish-green drainage. 3. Assist the client to start taking a clear liquid diet. 4. Assess the client for gas bloat syndrome.
1. Elevate the head of the bed at least 30 degrees. The primary concern in the immediate postoperative period is the potential for airway complications. Elevating the head at least 30 degrees decreases the chance for aspiration and facilitates respiratory effort.
A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing concept to consider when planning interventions for this client? 1. Elimination 2. Nutrition 3. Pain 4. Adherence
1. Elimination The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping.
In the care of a client with acute viral hepatitis, which task should be delegated to unlicensed assistive personnel (UAP)? 1. Emptying the bedpan while wearing gloves 2. Playing games or engaging the client in diversional activities 3. Monitoring dietary preferences 4. Reporting signs and symptoms of jaundice
1. Emptying the bedpan while wearing gloves The UAP should use infection control precautions for the protection of self, employees, and other clients.
The nurse is reviewing medication lists for clients who are being treated for peptic ulcer disease (PUD). The nurse is most likely to question the use of which medication? 1. Ibuprofen 2. Omeprazole 3. Amoxicillin 4. Clarithromycin
1. Ibuprofen one of the aggravating factors of PUD.
Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome? 1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. 2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention. 3. Observe for signs of secret purging and ingestion of water to increase weight. 4. Assess for alternating constipation and diarrhea and pale clay-colored stools.
1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention. Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload.
While transferring a dirty laundry bag, an unlicensed assistive personnel (UAP) sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome; the needle source is unknown. Place the following instructions, for the UAP, in the correct order of priority. - Have blood test(s) performed per protocol. - Complete and file an incident report. - Perform a thorough aseptic hand washing. - Report to the occupational health nurse. - Follow up for laboratory results and counseling. - Begin prophylactic drug therapy.
1. Perform a thorough aseptic hand washing. 2. Report to the occupational health nurse. 3. Have blood test(s) performed per protocol. 4. Begin prophylactic drug therapy. 5. Complete and file an incident report. 6. Follow up for laboratory results and counseling.
The nurse is caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication. - Cover the intestine with sterile moistened gauze. - Stay calm and stay with the client. - Check the vital signs, especially blood pressure and pulse. - Have a colleague gather sterile supplies and contact the health care provider (HCP). - Put the client into semi-Fowler position with knees slightly flexed. - Prepare the client for surgery as ordered.
1. Stay calm and stay with the client. 2. Put the client into semi-Fowler position with knees slightly flexed. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the health care provider (HCP). 5. Cover the intestine with sterile moistened gauze. 6. Prepare the client for surgery as ordered.
The home health nurse sees that the client is taking cimetidine. What question is the nurse most likely to ask to evaluate the efficacy of the therapy? 1. "Are you still having problems with constipation?" 2. "Has the medication helped to relieve the acid indigestion?" 3. "Did the medication relieve the nausea and vomiting?" 4. "Do you feel like your appetite has improved?"
2. "Has the medication helped to relieve the acid indigestion?" used to relieve heartburn, acid indigestion, and sour stomach.
The nurse must rearrange the room assignments for clients. Which clients would be best to put in the same room? Select all that apply. 1. A 35-year-old woman with copious intractable nausea and vomiting 2. A 43-year-old woman who underwent cholecystectomy 2 days ago 3. A 53-year-old woman with pain related to alcohol-associated pancreatitis 4. A 62-year-old woman with colon cancer receiving chemotherapy and radiation 5. A 70-year-old woman with stool culture results that show Clostridium difficile 6. A 55-year-old woman who is having symptoms after an exposure to norovirus
2. A 43-year-old woman who underwent cholecystectomy 2 days ago 3. A 53-year-old woman with pain related to alcohol-associated pancreatitis The client who had a cholecystectomy and the client with pancreatitis will need frequent pain assessments and medications.
The client has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. Which laboratory result will the nurse check first to see if the medication is having the desired effect? 1. White blood cell count 2. Ammonia level 3. Potassium level 4. Platelet count
2. Ammonia level The healthy liver breaks down ammonia, but in liver disease, the ammonia accumulates, and serum levels increase. Lactulose helps by enhancing intestinal excretion of ammonia.
For clients coming to the ambulatory care gastrointestinal clinic, which task would be most appropriate to assign to an LPN/LVN? 1. Teaching a client self-care measures for an ulcer 2. Assisting the health care provider to incise and drain a pilonidal cyst 3. Evaluating a client's response to sitz baths for an anorectal abscess 4. Describing the basic pathophysiology of an anal fistula to a client
2. Assisting the health care provider to incise and drain a pilonidal cyst Assisting with procedures for clients in stable condition with predictable outcomes is within the educational preparation of the LPN/LVN.
The nurse is taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon? 1. Obesity for approximately 5 years 2. History of counseling for body dysmorphic disorder 3. Failure to reduce weight with other forms of therapy 4. Body weight 100% above the ideal for age, gender, and height
2. History of counseling for body dysmorphic disorder Corrective surgery can exacerbate body dysmorphia when the client continues to feel dissatisfied with the results.
When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to unlicensed assistive personnel (UAP)? 1. Explaining the need for a clear liquid diet 2. Reinforcing "NPO" status 3. Administering laxatives as needed 4. Administering an enema to prepare the bowel
2. Reinforcing "NPO" status UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client.
A client with end-stage liver disease is talking to the nurse about being on the transplant list. Which statement by the client is cause for greatest concern? 1. "I have a family history of diabetes." 2. "I had symptoms of asthma when I was a kid." 3. "I guess I should cut back on my alcohol consumption." 4. "I am not very good about taking prescribed medication."
3. "I guess I should cut back on my alcohol consumption." Substance abuse may exclude a person from the transplant list, so the nurse should conduct additional assessment about this comment.
An older adult client tells the home health nurse that he puts 17 g of polyethylene glycol in a large cup of coffee every morning. Which assessment is the nurse most likely to perform first? 1. Assess the client for signs of dehydration or electrolyte imbalances. 2. Assess for signs and symptoms of overdose and then call Poison Control. 3. Ask the client to describe frequency and consistency of bowel movements. 4. Ask the client what he understands about the purpose of the medication.
3. Ask the client to describe frequency and consistency of bowel movements. taking the recommended dose of polyethylene glycol. Polyethylene glycol is used for the treatment of chronic constipation, so the nurse would assess the effect that the medication is having on bowel movements
The nurse is planning a treatment and prevention program for chronic bowel incontinence for an elderly client. Which intervention should the nurse try first? 1. Administer a glycerin suppository 15 minutes before evacuation time. 2. Insert a rectal tube at specified intervals each day. 3. Assist the client to the commode or toilet 30 minutes after meals. 4. Use incontinence briefs or adult-sized diapers.
3. Assist the client to the commode or toilet 30 minutes after meals. The goal of bowel training is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal.
The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader? 1. Obtaining an oversized blood pressure cuff and a large-size bed 2. Setting up a reinforced trapeze bar 3. Assisting in the planning of toileting, turning, and ambulation 4. Assigning tasks to unlicensed assistive personnel (UAP) and other ancillary staff
3. Assisting in the planning of toileting, turning, and ambulation The LPN/LVN can offer valuable assistance in planning the interventions, but the RN has ultimate responsibility for the care plan.
The nurse is caring for a client who was admitted to the medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to unlicensed assistive personnel (UAP)? 1. Check the client's skin temperature and report if the skin feels cool. 2. Check urometer every hour and observe for red- or pink-tinged urine. 3. Check vital signs every hour and report all of the values. 4. Check the client's pain and report worsening of pain or discomfort.
3. Check vital signs every hour and report all of the values. The UAP can take vital signs and report all of the values to the RN.
An older adult client tells the home health nurse that she is taking methylcellulose for chronic constipation. Which behavior is cause for greatest concern? 1. Client primarily eats white bread and drinks low-fat milk. 2. Client takes the methylcellulose three times a day. 3. Client takes the medication with a few sips of water. 4. Client does not promptly act on the urge to defecate.
3. Client takes the medication with a few sips of water. Methylcellulose can cause esophageal obstruction if taken with insufficient amounts of fluid.
The nurse is caring for a client with a nasogastric (NG) tube. Which task can be delegated to experienced unlicensed assistive personnel (UAP)? 1. Removing the NG tube at the prescribed time 2. Securing the tape if the client accidentally dislodges the tube 3. Disconnecting the suction to allow ambulation to the toilet 4. Reconnecting the suction after the client has ambulated
3. Disconnecting the suction to allow ambulation to the toilet Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse so that correct pressure is checked.
The nursing is supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. The nurse would intervene if the student performs which action? 1. Maintains the client in a semi-Fowler position 2. Checks the amount, color, and consistency of the drainage 3. Gently aspirates the drainage from the tube 4. Inspects the skin around the tube for redness or irritation
3. Gently aspirates the drainage from the tube T-tubes should not be irrigated, aspirated, or clamped without specific directions from the health care provider.
The nurse is caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. Which indicator is the most reliable for tracking fluid retention? 1. Auscultating the lung fields for crackles every day 2. Measuring the abdominal girth every morning 3. Performing daily weights with the same amount of clothing 4. Checking the extremities for pitting edema and comparing with baseline
3. Performing daily weights with the same amount of clothing All of these measures should be performed for total care of the client; however, weighing the client every day is considered the single best indicator of fluid volume.
In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Sharing successful strategies for weight reduction 2. Encouraging the client to express concerns about lifestyle modification 3. Reminding the client not to lie down for 2 to 3 hours after eating 4. Explaining the rationale for eating small frequent meals
3. Reminding the client not to lie down for 2 to 3 hours after eating Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP.
The client has a medical diagnosis of acute appendicitis. Which area of the abdomen is the client most likely to report abdominal pain and tenderness. 1. Right upper quadrant (RUQ) 2. Left upper quadrant (LUQ) 3. Right lower quadrant (RLQ) 4. Left lower quadrant (LLQ)
3. Right lower quadrant (RLQ) The client is likely to report pain and tenderness over the right lower quadrant (RLQ). Deep palpation should not be performed because of the possibility of rupture.
For clients with peptic ulcer disease (PUD), what is the most important lifestyle modification? 1. Avoiding caffeine 2. Decreasing alcohol intake 3. Smoking cessation 4. Controlling stress
3. Smoking cessation Smoking is associated with PUD.
A client with chronic hepatitis C has been taking the antiviral medication ledipasvir-sofosbuvir daily for the past month. Which information gathered during a home visit is most important for the nurse to communicate to the health care provider? 1. The client reports frequent headaches. 2. The client complains of feeling chronically tired. 3. The client occasionally misses a dose of the medication. 4. The client always takes the medication just before eating.
3. The client occasionally misses a dose of the medication. Effective treatment of chronic hepatitis C requires careful adherence to the medication regimen for the entire treatment time (usually 12 weeks).
The nurse is providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the health care provider? 1. The client cannot void 5 hours postoperatively. 2. The client reports shoulder pain. 3. The client reports right upper quadrant pain. 4. Output does not equal input for the first few hours.
3. The client reports right upper quadrant pain. sign of hemorrhage or bile leakage.
The charge nurse is reviewing the medication administration records for several clients. Which situation needs to be brought to the attention of the prescribing health care provider? 1. A client with gastroesophageal reflux disease is receiving magnesium hydroxide. 2. An older adult client with new-onset constipation is getting psyllium three times a day. 3. A client who needs a bowel prep is getting polyethylene glycol-electrolyte solution. 4. A client with abdominal pain secondary to diverticulitis is receiving bisacodyl.
4. A client with abdominal pain secondary to diverticulitis is receiving bisacodyl. Appendicitis, diverticulitis, ulcerative colitis, acute surgical abdomens, and bowel obstruction are contraindicated with the use of laxatives.
Which client is the most appropriate to assign to an LPN/LVN under the supervision of an RN? 1. A client with oral cancer who is scheduled in the morning for glossectomy 2. An obese client returned from surgery after a vertical banded gastroplasty 3. A client with anorexia nervosa who has muscle weakness and decreased urine output 4. A client with intermittent nausea and vomiting related to chemotherapy
4. A client with intermittent nausea and vomiting related to chemotherapy Administration of antiemetics and fluid monitoring can be done by an LPN/LVN.
A male nurse tells an older male client that he needs to perform a digital examination of the rectum to check for possible fecal impaction. The client responds, "I'm not letting any homosexual get near me." What should the nurse do first? 1. Explain that the procedure is a nursing action, not a sexual advance. 2. Ask the charge nurse to reassign that client to a different nurse. 3. Document that the client refused to allow the examination. 4. Ask the client if the presence of a female staff member would be acceptable.
4. Ask the client if the presence of a female staff member would be acceptable. The nurse is likely to feel upset, even angry; however, ideally, the nurse focuses on the client and tries to find a solution that allows the care to continue. Having a female witness in the room may reassure the client that nothing untoward will happen.
The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment finding is the most serious? 1. Projectile vomiting 2. Burning sensation 2 hours after eating 3. Coffee-ground emesis 4. Boardlike abdomen with shoulder pain
4. Boardlike abdomen with shoulder pain symptom of a perforation, which is the most lethal complication of PUD.
The nurse would be most concerned about a prescription for a total parenteral nutrition (TPN) fat emulsion for a client with which condition? 1. Gastrointestinal (GI) obstruction 2. Severe anorexia nervosa 3. Chronic diarrhea and vomiting 4. Fractured femur
4. Fractured femur A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution
A client with proctitis needs a rectal suppository. A senior nursing student assigned to care for this client tells the nurse that she is afraid to insert a suppository because she has never done it before. What is the most appropriate action in supervising this student? 1. Give the medication and tell the student to talk to the instructor. 2. Ask the student to leave the clinical area because she is unprepared. 3. Reassign the client to an LPN/LVN and send the student to observe. 4. Show the student how to insert the suppository and talk to the instructor.
4. Show the student how to insert the suppository and talk to the instructor. Showing the student how to insert the suppository meets both the immediate client need and the student's learning need. The instructor can address the student's fears and long-term learning needs after he or she is aware of the incident.
The nurse is caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate or assign for the care of this client? 1. Tell the unit secretary to call radiology and schedule a barium enema. 2. Ask the LPN/LVN to give as needed (PRN) laxatives when the client reports constipation. 3. Instruct the nursing student to help the client ambulate up and down the hall. 4. Tell unlicensed assistive personnel to save a stool specimen to test for occult blood.
4. Tell unlicensed assistive personnel to save a stool specimen to test for occult blood. Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood
The nurse is taking report on an elderly client who was admitted with abdominal pain and nausea, vomiting, and diarrhea. The client also has a history of chronic dementia. Which comment by the night shift nurse is most concerning? 1. The client has a flat affect and rambling and repetitive speech. 2. The client has memory impairments and thinks the year is 1948. 3. The client lacks motivation and demonstrates early morning awakening. 4. The client has a fluctuating level of consciousness and mood swings.
4. The client has a fluctuating level of consciousness and mood swings. associated more with acute delirium, which could be caused by many things, such as electrolyte imbalances, sepsis, or medications.