Saunders MED SURGE G.I questions
The nurse is caring for a client with suspected esophageal stricture. Which statement from the client supports this diagnosis?
"I've been having trouble swallowing meat." Rationale: Esophageal stricture is the narrowing of the lumen of the esophagus. A stricture can arise as a complication of another gastrointestinal condition, such as gastroesophageal reflux disease (GERD) due to the growth of scar tissue in response to chronic inflammation. The narrowing of the esophageal lumen can cause dysphagia, or trouble swallowing
An acutely ill-looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data would the nurse collect to assist in validating this suspicion? Select all that apply.
- Inspect the abdomen for rigidity. -Check for the presence of hiccups. -Inspect the client's mucous membranes. Rationale: The nurse would assess for hiccups because this is a sign of diaphragmatic irritation. Tachycardia, not bradycardia, and hypoactive or absent bowels sounds, not hyperactive bowel sounds, would be present in peritonitis. Abdominal rigidity is a classic sign of peritonitis, a potentially life-threatening acute inflammatory disorder.
The client arrives at the clinic complaining of dyspepsia and pain that occurs about 90 minutes after eating. The client also reports that the pain became worse this afternoon about 3 hours after eating a large bowl of spaghetti with tomato sauce. Laboratory tests reveal the presence of Helicobacter pylori (H. pylori). The nurse anticipates that the primary health care provider would prescribe which medications? Select all that apply.
-Esomeprazole -Metronidazole -Clarithromycin Rationale: The client is describing symptoms associated with a duodenal ulcer. Clarithromycin and metronidazole are two of the antibiotics frequently prescribed to treat H. pyloriinfection, which is a common cause of duodenal ulcers. A proton pump inhibitor, like esomeprazole, is prescribed to help decrease gastric acid secretions. Tums is contraindicated because it can trigger gastrin release resulting in rebound acid secretion and more pain. The ibuprofen (like all NSAIDs) can aggravate the ulcer.
A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse would schedule the medication so that each dose is taken at which time?
30 minutes before meals Rationale: To be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtime.
The nurse has been reinforcing dietary teaching for a client diagnosed with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?
A decrease in sour eructation Rationale: A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome
A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse would most appropriately suggest which diet during the acute phase?
A low-fiber diet Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is usually prescribed during the acute phase for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. Once the acute phase has subsided, the primary health care provider usually prescribes a high fiber diet. Neither a low-fat diet, a high-fat diet, nor a high-carbohydrate diet will aid in symptom management in acute diverticulitis.
The nurse is caring for a client diagnosed with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?
A pair of scissors Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress that occurs if the gastric balloon ruptures moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and a Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.
The client arrives at an emergency department complaining of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the primary health care provider's prescriptions. Which prescription would the nurse most likely question if written on the primary health care provider's prescription form?
Administration of an opioid analgesic Rationale: Until a differential diagnosis is determined and a decision about the need for surgery is made, the nurse should question a prescription to give an opioid analgesic because it could mask the client's symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of an NG tube may be helpful to provide decompression of the stomach.
A client with viral hepatitis states to the nurse, "I am so yellow." The nurse would best respond by taking which action?
Assist the client in expressing feelings. Rationale: The client's feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned.
When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, which foods would the nurse tell the client are best to include in the diet for this disorder? Select all that apply.
Beans Whole-grain bread Rationale: A high-fiber, high residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products.
The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse would conclude which is the problem, and what action would be taken?
Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying. Rationale: Turning the client regularly helps collapse the channels and promotes gastric emptying. The tube already has been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a serious complication.
A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client would take which action to monitor the effectiveness of treatment?
Checking the frequency and consistency of bowel movements Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea.
The nurse is caring for a client with a diagnosis of anal fistula. Which condition would the nurse most likely expect to note in the client's medical history?
Crohn's disease Rationale: Anal fistulas are abnormal openings or tunneling leading from the anus or from the rectum. These fistulas are a complication associated with Crohn's disease and occur as a result of the inflammatory changes in Crohn's.
A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse would gather further information about the presence of which sign or symptom?
Difficulty swallowing Rationale: Although many clients with hiatal hernia are asymptomatic those with symptoms usually have difficulty swallowing, along with heartburn and reflux. Dizziness after meals, left lower quadrant pain 2 hours after eating, and moderate right upper quadrant pain unrelated to eating are unrelated to this disorder.
Which infection control method would the nurse determine to be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure?
Hepatitis B vaccine Rationale: Immunization is the most effective method of preventing hepatitis B infection
The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse would identify which intervention in the plan of care for the client as the priority?
Monitoring the insertion site for signs of infection Rationale: Total parenteral nutrition that is infusing via a central line, such as through the subclavian vein, is more likely to become infected than a standard peripheral intravenous line. Infection may quickly lead to sepsis. At least every 4 to 6 hours, the insertion site should be inspected.
The nurse is assisting in caring for a client who suffered blows to the face with a baseball bat and a gunshot wound to the abdomen. The nurse is reviewing the prescriptions in the client's medical record and determines there is a need for follow-up with the primary health care provider if which prescription is noted?
Nasogastric tube insertion Rationale: Nasogastric tube insertion is contraindicated in the client that has evidence of facial trauma, such as the client that received blows to the face with a blunt object, because it could cause more harm. The nurse would contact the primary health care provider regarding this prescription, as this is an unsafe intervention for this client. Obtaining a type and crossmatch and a CBC are appropriate nursing interventions. Warm IV fluids would help prevent hypothermia in the trauma client.
The client has a prescription for sucralfate 1 g by mouth 4 times daily. The nurse would best schedule the administration of the medication at which time?
One hour before meals and at bedtime Rationale: Sucralfate is a medication that should be scheduled for administration 1 hour before meals and at bedtime. The medication is scheduled so that it has time to form a protective coating over the ulcer before food intake stimulates chemical and mechanical irritation.
A client that is postgastrectomy is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse would plan to monitor which data?
Postprandial blood glucose readings Rationale: Late symptoms of dumping syndrome following a gastrectomy occur 2 to 3 hours after eating and result from a rapid entry of increased carbohydrate food into the jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this, the nurse checks the blood glucose level 2 hours after meals.
The nurse is caring for a client diagnosed with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed the nasogastric tube to be discontinued. To best determine the client's readiness for discontinuation of the nasogastric tube, which measure would the nurse check?
Presence of bowel sounds in all four quadrants Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction, and a nasogastric tube may be used to empty the stomach and relieve distention and vomiting. Bowel sounds return to normal as the obstruction is relieved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function returns may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate are important assessments for the client with a nasogastric tube in place, but these would not assist in determining the readiness for removing the nasogastric tube.
The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse would determine that which data noted in the record indicate poor absorption of dietary fats?
Steatorrhea Rationale: The pancreas makes digestive enzymes that aid absorption. Chronic pancreatitis interferes with the absorption of nutrients. Fat absorption is limited because of the lack of pancreatic lipase. Steatorrhea by definition is excess fat in stools often caused by malabsorption problems.
The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription would the nurse verify if noted in the client's chart?
Supine and flat client positioning Rationale: The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription.
A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN would assist the client into which most appropriateposition?
Supine with the head raised slightly and the knees slightly flexed Rationale: To perform an abdominal assessment, the client is placed in the supine position with the head raised slightly and the knees slightly flexed. This position will relax the abdominal muscles.
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?
Sweating and pallor Rationale: Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates a need for further teaching?
The tube will be inserted through my mouth to my stomach. Rationale: A Sengstaken-Blakemore tube may be used to control bleeding of esophageal varices when other interventions have been ineffective. It is inserted by the primary health care provider via the nose into the esophagus and stomach.
The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement would the nurse make to the client for consideration?
"Be sure to sleep with your head elevated in bed." Rationale: Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.
The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?
"I need to decrease fiber in my diet." Rationale: Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract.
The nurse is teaching the client with vitamin B12 deficiency about foods that are good sources of vitamin B12. The nurse identifies a need for further teaching if the client states which foods are good sources of vitamin B12? Select all that apply.
-Broccoli -Citrus fruits Rationale: Foods that are high in vitamin B12 are typically animal products, such as meat, fish, and dairy products. Therefore, the options that include non-animal products such as fruits and vegetables are not substantial sources of vitamin B12, making the correct answer options 3 and 4, broccoli and citrus fruits.
A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions would be included in the procedure? Select all that apply.
-Explain the procedure to the client. -Ask the client to take a deep breath and hold. -Pull the tube out in one continuous steady motion. -Remove the device or tape securing the tube from the nose. Rationale: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull.
The nurse is administering pantoprazole to a client with gastroesophageal reflux disease (GERD). The nurse understands that pantoprazole has which potential adverse effects? Select all that apply.
-Fractures -Pneumonia -Hypomagnesemia Rationale: Pantoprazole belongs to the drug class called proton pump inhibitors (PPIs). Long-term PPI use is linked to osteoporosis, which weakens bones and increases the client's risk for fractures. PPIs are thought to alter the upper gastrointestinal flora and impair white blood cell function, increasing the risk of pneumonia. Additionally, long-term PPI use can lower serum magnesium levels due to poor intestinal absorption of magnesium, which can result in hypomagnesemia. Low hemoglobin and hypokalemia are not adverse effects of pantoprazole.
The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations would the nurse include in the teaching session? Select all that apply.
-It is advisable to stop smoking cigarettes. -Wait at least 1 hour after meals to perform chores -Be sure to elevate the head of the bed during sleep. Rationale: The client should elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Smoking cigarettes increases acid secretion, so the client sh ould be advised to stop smoking. The consumption of low-fat or nonfat foods is recommended, not moderate fat. The client should remain upright for an hour after eating.
The nurse is reviewing a client's medications. The nurse determines which medications increase the client's risk of dehydration? Select all that apply.
-Lactulose -Spironolactone -Polyethylene glycol Rationale: Lactulose and polyethylene glycol are osmotic laxatives that draw water into the intestine to soften stool and stimulate a bowel movement, therefore excreting water through the stool, which can dehydrate if fluids are not replaced. Spironolactone is a potassium-sparing diuretic that promotes diuresis and increases the risk of dehydration.
A client has a diagnosis of asymptomatic diverticular disease. Which type of diet would the nurse anticipate being prescribed?
High-fiber diet Rationale: A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation
The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?
Cimetidine results in decreased secretion of stomach acid. Rationale: Cimetidine and other histamine H2-receptor antagonists decrease the secretion of gastric acid in the stomach. Antacids neutralize acid in the stomach. Omeprazole inhibits gastric acid secretion. Sucralfate promotes healing by coating the ulcer.
The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding would the nurse recognize to be a direct result of this client's condition?
Drowsiness Rationale: Hepatitis impairs liver function. If the liver is unable to perform its metabolic and detoxification functions, waste products begin to accumulate in the body. Many of those wastes are protein by-products, especially ammonia, which are harmful to the central nervous system. An increased ammonia level is the primary cause of the neurological changes seen in liver disease, beginning with drowsiness.
A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom associated with a hiatal hernia would the nurse recognize?
Heartburn and regurgitation Rationale: Although many clients with a hiatal hernia are asymptomatic, those with symptoms usually have difficulty swallowing along with heartburn and reflux. Dry cough, left lower quadrant pain, and moderate right upper quadrant pain are not related to this disorder.
The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which statement made by the client indicates a need for further teaching?
I will eat a bland diet only. Rationale: A bland diet is unnecessary. The client should not skip meals, but tea and coffee should be avoided because they cause an increase in acid production. Spicy foods should be discontinued if they cause pain.
A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom would the nurse expect to observe based on this diagnosis?
Fatigue Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas—small, dilated blood vessels—are commonly seen in cirrhosis of the liver.
The nurse is interpreting the laboratory results of a client who has a history of diagnosed chronic ulcerative colitis. The nurse would determine that which result indicates a complication of ulcerative colitis?
Hemoglobin 10.2 g/dL Rationale: A normal hemoglobin level ranges from 12 to 16 g/dL. The client with ulcerative colitis is most likely anemic because of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. The other laboratory results are within a normal range.
A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse would determine that which data would further support this diagnosis?
History of chronic obstructive pulmonary disease with weight loss Rationale: History of chronic obstructive pulmonary disease is commonly associated with gastric ulcers, because this disease increases gastric acid secretion. Weight loss is also associated with gastric ulcer disease. The other options do not contain risk factors or symptoms commonly associated with this disorder.
After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?
Limit bleeding from the biopsy site Rationale: After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site.
A client has been diagnosed with acute gastroenteritis. Which diet would the nurse anticipate to be prescribed for the client?
Low fiber Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea.
A client diagnosed with acute pancreatitis is experiencing severe pain from the disorder. The nurse would instruct the client to avoid which position that could aggravate the pain?
Lying flat Rationale: Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions.
The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation would indicate that a prolapse has occurred?
Protruding and swollen Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color.
A client diagnosed with a peptic ulcer scheduled for a vagotomy asks the nurse about the purpose of this procedure. The nurse would explain to the client that a vagotomy primarily serves which purpose?
Reduces the stimulation of acid secretions Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Halting stress reactions, healing the gastric mucosa, and decreasing food absorption in the stomach are incorrect descriptions of a vagotomy.
The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse would plan care knowing that which could most result in a potential complication?
Vigorous coughing Rationale: Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure.
A client reports excessive sweating, muscular weakness, diarrhea, and achiness in the bones. The nurse suspects the client is deficient in which vitamin?
Vitamin D Rationale: Muscular weakness, excessive sweating, diarrhea, bone pain, and osteomalacia is associated with vitamin D deficiency. Vitamin K deficiency is associated with dysfunctional blood coagulation. Vitamin C deficiency is associated with bleeding gums, loose teeth, poor wound healing, scurvy, and dry and itchy skin. Vitamin B6deficiency is associated with seizures, anemia, neuropathy, weakness, and anorexia.
A client with Crohns's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery?
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 assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client?
Learn measures such as biofeedback or progressive relaxation. Rationale: Treatment for irritable bowel syndrome includes stress reduction measures such as biofeedback, progressive relaxation, and regular exercise. The client should also learn to limit responsibilities. Other measures include increased fluid and fiber in the diet as prescribed and antispasmodic or sedative medications as needed.
A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN would include which instruction in this discussion?
Remove all metal and jewelry before the test Rationale: A barium swallow, or esophagography, is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test, so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on primary health care provider instructions. Most oral medications also are withheld before the test. The client should self-monitor for constipation after the procedure, which can occur from barium in the GI tract.
A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse would take which immediate action?
Take the client's vital signs. Rationale: The nurse should take the client's vital signs first to determine if the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. The registered nurse also is notified. Although an NG tube may be inserted, this is not the immediate action. A complete history would be obtained and an abdominal assessment would be done once the client is stable.
The nurse analyzes the results of laboratory studies performed on a client with diagnosed peptic ulcer disease (PUD). Which laboratory value would most indicate a complication associated with the disease?
Hemoglobin 10.2 g/dL Rationale: The most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low hemoglobin and hematocrit level indicate bleeding. The normal hemoglobin range in females is 12 to 16 g/dL and in males is 14 to 18 g/dL. A white blood cell count is performed to indicate the presence of infection or inflammation. The normal white blood cell count is 5000 to 10,000 mm3. The normal platelet range is 150,000 to 400,000 mm3. The creatinine measures renal function. The normal value is 0.6 to 1.3 mg/dL.
The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus?
Inability to pass flatus Rationale: An inflammatory reaction, such as acute pancreatitis, can cause paralytic ileus the most common form of nonmechanical obstruction. Inability to pass flatus is a sign/symptom of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, nontender mass palpable at the lower right costal margin describes the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, it is not a sign of paralytic ileus or intestinal obstruction.
The nurse should include which most appropriate information when reinforcing home care instructions for a client who has been diagnosed with peptic ulcer disease?
Learn to use stress reduction techniques. Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client also should avoid intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.
The nurse understands that the client with a Clostridium difficile (C. difficile) infection is at increased risk for which acid-base imbalance?
Metabolic acidosis Rationale: C. difficile causes frequent episodes of watery diarrhea. The client is at risk for metabolic acidosis, as bicarbonate is lost through the lower gastrointestinal tract.
The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse would question which prescription?
Milk of magnesia Rationale: A client with right lower quadrant pain may have appendicitis. This client should be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; therefore, the nurse should question this prescription.
A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action?
Monitoring prothrombin and partial thromboplastin values Rationale: When liver function is impaired, as in the client with hepatitis, some important body functions do not occur. The liver synthesizes fibrinogen, prothrombin, and factors needed for normal blood clotting. Without those clotting ingredients, bleeding may occur either internally or externally. Monitoring coagulation studies provides the nurse with information needed to plan ways to reduce the risk of hemorrhage when providing care. Daily weight is often part of a nursing care plan but is more related to fluid balance than safety; monitoring weight twice daily would not be necessary. Tepid baths may decrease the pruritus associated with jaundice, but this is not a safety issue either.
The nurse is caring for a client in the pre-operative period scheduled for a hemorrhoidectomy. The nurse would inform the surgeon about which medication, if noted in the client's home medication list?
Clopidogrel Rationale: Clopidogrel is an antiplatelet medication used to prevent cardiovascular events, which is associated with an increased risk of bleeding, especially during surgery. Lisinopril is an angiotensin-converting enzyme inhibitor that is used to manage hypertension and heart failure. A common adverse effect is hyperkalemia. Atorvastatin is an HMG-CoA reductase inhibitor, also known as a statin, which is used to manage hyperlipidemia. A common adverse effect is liver injury. Amiodarone is an antidysrhythmic medication used to manage heart rhythm problems. A common adverse effect is pulmonary toxicity.
The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which action would the nurse encourage the client to do?
Eat anything as long as it does not aggravate or cause pain. Rationale: The client may eat foods as long as they do not aggravate or cause pain. Increased GI motility should be avoided. A traditional bland diet is no longer recommended. It is unnecessary for the client to eat 6 small meals per day with this disorder, although smaller meals are better managed by the client.
The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse would determine which data indicates the client may have liver damage?
Pruritus Rationale: Significant damage to liver cells renders them unable to metabolize bilirubin. When a red blood cell is broken down, hemoglobin is released. The heme portion is catabolized into unconjugated bilirubin. The liver then takes that unconjugated bilirubin and transforms it into conjugated bilirubin that passes into the hepatic ducts and eventually into the bowel, providing the normal brown color to stool. When bilirubin is not metabolized by the liver, it accumulates in the circulation and is minimally excreted by the skin, causing jaundice and pruritus. It is also eliminated unchanged by the kidneys, causing urine to become dark amber or brown.
Atropine sulfate is prescribed for the client diagnosed with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, most indicates the need to contact the primary health care provider before administering the medication?
Narrow-angle glaucoma Rationale: Atropine sulfate can cause mydriasis (dilation of the pupil) and cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma.
The nurse working in the emergency department is assisting with an initial assessment on a client who is complaining of severe upper abdominal pain that spreads throughout the abdomen and radiates to the back and shoulders. The client has tried taking antacids with no relief. On assessment the abdomen is rigid and bowel sounds are absent. Which data in the client's history would the nurse be most concerned about in connection with these assessment findings?
Peptic ulcer disease Rationale: Given the clinical presentation for this client, the nurse would be most concerned about a reported history of peptic ulcer disease, because a complication of this disease is bowel perforation from an ulcer. With the findings of severe upper abdominal pain spreading through the abdomen and radiating to the back and shoulders, unrelieved by antacids, and rigid abdomen with absent bowel sounds, the nurse would suspect an acute abdomen problem. Colon cancer, diverticulosis, and chronic pancreatitis are chronic conditions that have less of a risk of causing an acute abdomen condition when compared to peptic ulcer disease. In addition, colon cancer and diverticulitis are most likely to cause lower abdominal pain. Chronic pancreatitis is more likely to cause left sided mid-abdominal pain.
The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed? Select all that apply.
-Administer antacids, as prescribed. -Encourage coughing and deep breathing. -Administer anticholinergics, as prescribed. Rationale: The client with acute pancreatitis is normally placed on a nothing-by-mouth (NPO) status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded, abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.
A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?
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 HOB should be elevated 30 to 45 degrees for 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat or supine position should be avoided because of the risk of aspiration.
The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?
Fever and pruritic urticaria Rationale: IV fat emulsions are sometimes administered with parenteral nutrition to supply needed calories and essential fatty acids. This fat emulsion must be infused by pump at a set rate, usually over 10 to 12 hours. Signs and symptoms of fat overload include fever, leukocytosis, hyperlipidemia, and pruritic urticaria, and focal seizures are possible.
The client is taking docusate sodium. The nurse would monitor which result to determine if the client is having a therapeutic effect from this medication?
Regular bowel movements Rationale: Docusate sodium is a stool softener that promotes the absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, stop gastrointestinal (GI) bleeding, or decrease the amount of fat in the stools.
A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
Fluid overload Rationale: The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis
The nurse is assessing a client who fell at home and is complaining of abdominal pain. The nurse notes ecchymosis on the client's flanks and documents this as which assessment finding?
Grey Turner's sign Rationale: Grey Turner's sign is ecchymosis present on the flanks and can be a sign of retroperitoneal hemorrhage. Cullen's sign is similar, except the ecchymosis is present around the umbilicus and can also indicate retroperitoneal hemorrhage. Murphy's sign is present in cholecystitis and is elicited by placing the hand on the client's right upper abdominal quadrant and asking the client to breathe deeply. If pain is present, Murphy's sign is positive. Brudzinski's sign is positive if the client's hips and knees flex when the neck is flexed and can be indicative of meningitis.
The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history would the nurse determine is least likely associated with this disease?
History of the use of acetaminophen for pain and discomfort Rationale: Unlike aspirin (acetylsalicylic acid), acetaminophen has little effect on platelet function, doesn't affect bleeding time, and generally produces no gastric bleeding. History of alcohol abuse, tarry black stools, and gastric pain 2 to 4 hours after meals, if reported by the client, are indications of peptic ulcer disease.
A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse would suggest contacting the primary health care provider to request a prescription for which medication?
Hydromorphone Rationale: Hydromorphone rather than morphine is the medication of choice because morphine can cause spasms in the sphincter of Oddi. Acetylsalicylic acid and acetaminophen with codeine are inappropriate medications because they are not potent enough and because they require the oral route. The client with acute pancreatitis should take nothing by mouth (NPO).
The nurse caring for a client with a small bowel obstruction monitors for complications of this condition. Which acid-base imbalance would the nurse most likelyexpect to occur in this condition?
Metabolic alkalosis Rationale: Dehydration and electrolyte imbalances, as well as acid-base imbalances, are common for clients with bowel obstruction. A client with an upper bowel obstruction is more likely to have metabolic alkalosis usually due to vomiting and loss of acids, while a client with a lower obstruction is at greater risk for metabolic acidosis. The small bowel is part of the upper bowel. Respiratory acidosis and alkalosis are not specifically related to bowel obstruction.
