Pass Point Q's Gastrointestinal/Integumentary Disorders

A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions? "I'll exercise to increase my intra-abdominal pressure." "I'll take all of my antibiotics." "I'll decrease the fiber in my diet." "I'll reduce my fluid intake."

"I'll take all of my antibiotics." R:Antibiotics are used to reduce inflammation. The client with acute diverticulitis typically isn't allowed anything orally until the acute episode subsides. Parenteral fluids are given until the client feels better; then it's recommended that the client drink eight 8-oz (237-ml) glasses of water per day and gradually increase fiber in the diet to improve intestinal motility. During the acute phase, activities that increase intra-abdominal pressure should be avoided to decrease pain and the chance of intestinal obstruction.

The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply. Request a prescription for an antibiotic prior to going. Use an antibiotic ointment prophylactically on skin. Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others.

Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others. R:It is important to keep cuts and scrapes clean and covered to prevent bacterial invasion by staphylococcus aureus and other bacteria. Hands should be washed with soap and water after activities and contact with potential sources of infection. Do not share personal objects with others such as towels, razors, etc. The use of prophylactic antibiotic ointment may cause problems with antibiotic resistance and should be discouraged.

Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease? To keep gastric pH at 3.0 to 3.5 To maintain a regular bowel pattern To promote client compliance To increase pepsin activity

To keep gastric pH at 3.0 to 3.5 R:To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance. Antacids don't regulate bowel patterns, and they decrease pepsin activity.

Following a liver transplant a client develops ascites. The nurse should teach the client to: increase water intake. reduce requests for pain medicine. perform 10 leg raises every waking hour. brace the abdomen with a pillow during coughing.

brace the abdomen with a pillow during coughing. R:Bracing the abdomen during coughing will reduce the risk of wound dehiscence following liver transplantation. Ascites is fluid retention in the abdomen; therefore, increasing water ingestion isn't indicated. However, excessive ascites may lead to hypovolemia therefore the client should be assessed for fluid volume deficit. Leg raises will put unwanted tension on the abdominal wound. Pain control is important after surgery to provide for client comfort. It wouldn't be appropriate to suggest that the client reduce his requests.

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may: dislodge the autografts. decrease circulation to the fingers. increase the amount of scarring. increase edema in the arms.

dislodge the autografts. R:Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. None of the other options results from exercise.

A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A?

fecal contamination and oral ingestion R:Hepatitis A is predominantly transmitted by the ingestion of fecal contaminated food. Transmission is more likely to occur with poor hygiene, crowded conditions, and poor sanitation. Hepatitis B and C are transmitted via exposure to contaminated blood and blood products; such exposure can occur during sexual activity with an infected partner or by sharing contaminated needles or syringes.

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? teaching the client how to collect a urine specimen weighing the client teaching the client coughing and deep breathing exercises initiating I.V. therapy, as ordered

initiating I.V. therapy, as ordered R:The RN must confirm that the LPN has specialized I.V. training before asking the LPN to begin I.V. therapy for this client. Initiating I.V. therapy is beyond the usual scope of practice for an LPN. Weighing the client, teaching coughing and deep breathing exercises, and teaching the client how to collect a urine specimen are within the scope of LPN practice and don't require additional training.

When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is: planning for the client's rehabilitation and discharge. maintaining the client's fluid, electrolyte, and acid-base balance. providing emotional support to the client and family. preserving full range of motion in all affected joints.

maintaining the client's fluid, electrolyte, and acid-base balance. R:The most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life- threatening complications, such as shock, disseminated intravascular coagulation (DIC), respiratory failure, cardiac failure, and acute tubular necrosis. The other options are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?

Anticholinergic drugs R:Paregoric has an additive effect of constipation when used with anticholinergic drugs. Antiarrhythmics, anticoagulants, and antihypertensives aren't known to interact with paregoric.

The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)?

Assist the client in cleaning around the Unna boot. R:The Unna boot is a non-elastic paste bandage boot that can be used to treat uninfected, non-necrotic leg and foot ulcers that result from such conditions as venous insufficiency and stasis dermatitis. The dressing wraps around the affected foot and leg. The boot's effectiveness results from compression applied by the bandage, which decreases edema, combined with moisture supplied by the paste. An Unna boot is contraindicated in clients who are allergic to any ingredient used in the paste and in clients with arterial ulcers, weeping eczema, or cellulitis. Evaluating the boot effectiveness, the foot sensation/movement, and capillary refill, in addition to teaching the family about the signs of infection, are tasks for the nurse with more education and a license.

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 R:Autonomy refers to an individual's right to make their own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.

The nurse is reinforcing prior education for a client on how to prevent development of basal cell epithelioma. Which information is most important for the nurse to tell the client?

Avoid exposure to sun. R:The sun is the best known and most common cause of basal cell epithelioma. Thermal burns, immunosuppression, and radiation are less common causes.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's dusky-appearing stoma is related to which factor? Blood supply to the stoma has been interrupted. An intestinal obstruction has occurred. The ostomy bag should be adjusted. This is a normal finding 1 day after surgery.

Blood supply to the stoma has been interrupted. R:An ileostomy stoma is formed by bringing the ileum through the abdominal wall to the skin surface, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

Cancer of the cervix. R:A female client with genital herpes simplex is at increased risk for cervical cancer. Genital herpes simplex isn't a risk factor for cancer of the ovaries, uterus, or vagina.

A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition? carbon monoxide poisoning hydrocarbon ingestion aspirin ingestion overdose spider bite

Carbon monoxide poisoning R:Cherry-red skin indicates exposure to high levels of carbon monoxide. Spider bite reactions are usually localized to the area of the bite. Nausea and vomiting and pale skin are symptoms of aspirin ingestion overdose. Hydrocarbon or petroleum ingestion usually causes respiratory symptoms and tachycardia.

The ingestion of substances containing lead is mostly influenced by which risk factor?

Child's age. R:The highest risk of lead poisoning occurs in young children who tend to put things in their mouths. In older homes that contain lead-based paint, paint chips may be eaten directly by the child, or they may cling to toys or hands that are then put into the child's mouth. Poisoning isn't gender-related. Blacks have a higher incidence of lead poisoning, but it can happen in any race. Children of low socioeconomic status are more likely to eat lead-based paint chips. Most parents don't eat lead-based paint on purpose.

Which action by the nurse displays client advocacy during a skin assessment? Transferring the client in the other bed out of the room. Asking the client if he has any skin lesions Performing a visual inspection of the skin Ensuring client privacy by pulling the curtain closed

Ensuring client privacy by pulling the curtain closed R:Closing the client's curtain during a skin assessment demonstrates client advocacy. The nurse should inspect the client's skin for lesions and not rely on the client to inform her if any exist. Performing a visual inspection is part of the skin assessment process, but it doesn't demonstrate client advocacy. It isn't necessary to transfer the client in the other bed out of the room.

The nurse is caring for a client that has taken an overdose of acetaminophen. For which initial complication should the nurse closely monitor the client?

Hepatic Damage R:The damage to the hepatic system is not from acetaminophen, but from one of its metabolites. This metabolite binds to liver cells in large quantities. Brain damage and heart failure may develop later, but not initially. Kidney stones are not complications of acetaminophen overdose.

A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do?

Notify the client's physician. R:Because the client is not receiving adequate pain relief from the fentanyl patch, the client's physician should be notified. It is inappropriate to replace the patch early. Massaging the patch or applying warmth to it may increase the drug's absorption, but these are not acceptable practices because the patch is designed to release the drug at a controlled rate over a 3-day period.

A client who has suffered a stroke is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: reduce the client's fluid intake. encourage the client to use a footboard. turn him frequently. perform passive range-of-motion (ROM) exercises.

turn him frequently. R:The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.