NCLEX Lower Gastrointestinal Tract Questions
Lower Gastrointestinal Tract NCLEX Practice Questions
Question 1.
Which guideline reflects the current American and Canadian Cancer Societies’ recommendations for screening for colon cancer in individuals who are not at high risk?
(a) Annual digital rectal examination should begin at age 40.
(b) Annual fecal testing for occult blood should begin at age 50.
(c) Individuals should obtain a baseline barium enema at age 40.
(d) Individuals should obtain a baseline colonoscopy at age 45.
Answer:
(b) Annual fecal testing for occult blood should begin at age 50.
Explanation:
Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they experience signs or symptoms that indicate the need for such diagnostic testing or are considered to be at high risk.
Question 2.
A client refuses to look at or care for their colostomy. Which statement by the nurse would be most appropriate?
(a) “It’s been 4 days since your surgery, and you’ll soon be discharged. You have to learn to care for your colostomy before you leave the hospital.”
(b) “I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.”
(c) “I understand how you are feeling. It is important for you to feel attractive, and you think having a colostomy changes your attractiveness.”
(d) "I can see that you are upset. Would you like to share your concerns with me?”
Answer:
(d) "I can see that you are upset. Would you like to share your concerns with me?”
Explanation:
It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling.
Question 3.
The nurse should teach clients about which potential risk factor for the development of colon cancer?
(a) chronic constipation
(b) long-term use of laxatives
(c) history of smoking
(d) history of inflammatory bowel disease
Answer:
(d) history of inflammatory bowel disease
Explanation:
A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or low-fiber diet.
Question 4.
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), what should the nurse do first?
- 1000 mL normal saline every 8 hours at 125 gtts/h
- Vital signs every 4 hours
- Morphine sulfate 10 mg IV every 4 hours as needed for pain
- Nothing by mouth Oxygen 2-4 L/min per mask
(a) Take the vital signs every hour.
(b) Increase the saline infusion to 150 gtts/h.
(c) Administer oxygen at 2 L/min.
(d) Determine when last pain medication was administered.
Answer:
(c) Administer oxygen at 2 L/min.
Explanation:
This client has decreased oxygen saturation and also decreased hemoglobin, which puts the client at great risk for cardiac ischemia. The nurse should start the oxygen as prescribed. The nurse can take the vital signs more frequently once the oxygen flow has been started. It is not appropriate to increase the rate of the intravenous infusion, and it would be necessary to request a prescription to do so. After starting the oxygen, the nurse can ask the client about the current pain level.
Question 5.
A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?
(a) laxative
(b) anticholinergic
(c) antacid
(d) demulcent
Answer:
(a) laxative
Explanation:
After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.
Question 6.
A client has a nasogastric tube inserted at the time of abdominal-perineal resection with permanent colostomy for colon cancer. When should the nurse tell the client that the tube will most likely be removed?
(a) absence of nausea and vomiting
(b) passage of mucus from the rectum
(c) passage of gas and fecal material from the colostomy
(d) absence of stomach drainage for 24 hours
Answer:
(c) passage of gas and fecal material from the colostomy
Explanation:
A sign indicating that a client’s colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned.
Question 7.
The client with colon cancer has an abdominal-perineal resection with a colostomy. To promote hygiene following surgery, what should the nurse do?
(a) Maintain the client in a semi-Fowler’s position.
(b) Assist the client with warm sitz baths.
(c) Administer 30 mL of milk of magnesia to stimulate peristalsis.
(d) Remove the ostomy pouch as needed so the stoma can be assessed.
Answer:
(b) Assist the client with warm sitz baths.
Explanation:
Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal inci-sion. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage.
Question 8.
The nurse assesses the client’s stoma during the initial postoperative period. What observation should the nurse report to the health care provider (HCP) immediately?
(a) The stoma is slightly edematous.
(b) The stoma is dark red to purple.
(c) The stoma oozes a small amount of blood.
(d) The stoma does not expel stool.
Answer:
(b) The stoma is dark red to purple.
Explanation:
A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing of blood are normal in the early postoperative period. The colostomy would typically not begin functioning until 2 to 4 days after surgery.
Question 9.
While changing the client’s colostomy bag and dressing, what will indicate to the nurse that the client is ready to participate in self-care?
(a) The client asks if the health care provider (HCP) will change the dressing soon.
(b) The client asks about the supplies used during the dressing change.
(c) The client talks about the news on the television.
(d) The client is upset about the way the night nurse changed the dressing.
Answer:
(b) The client asks about the supplies used during the dressing change.
Explanation:
A client who displays interest in the procedure and asks about supplies used for dressings may be ready to participate in self-care. Inquiring about when the HCP [2 will change the dressing does not indicate the client’s readiness to change the dressing. Discussing news events and discussing a dressing change are behaviors that avoid the subject of the colostomy.
Question 10.
The nurse is instructing the client with a new colostomy about protecting the skin around the colostomy. Which skin barrier should the nurse tell the client is best to apply around the colostomy?
(a) adhesive skin barrier
(b) petroleum jelly
(c) cornstarch
(d) antiseptic cream
Answer:
(a) adhesive skin barrier
Explanation:
An adhesive skin barrier is effective for protecting the skin around a colostomy to keep the skin healthy and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy bag.
Question 11.
When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction?
(a) Foods containing roughage should not be eaten.
(b) Liquids are best limited to prevent diarrhea.
(c) Clients should experiment to find the diet that is best for them.
(d) A high-fiber diet will produce a regular passage of stool.
Answer:
(c) Clients should experiment to find the diet that is best for them.
Explanation:
It is best to adjust the diet of a client with a colostomy in a manner that suits the client rather than trying special diets. Severe restriction of roughage is not recommended. The client is encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.
Question 12.
The nurse is teaching a client who is recovering from an abdominal-perineal resection with a colostomy about health promotion. What is an expected outcome for a client during the first 2 weeks after surgery?
(a) maintaining a fluid intake of 3,000 mL/day
(b) eliminating fiber from the diet
(c) limiting physical activity to light exercise
(d) accepting that sexual activity will be diminished
Answer:
(a) maintaining a fluid intake of 3,000 mL/day
Explanation:
An expected outcome is that the client will maintain a fluid intake of 3,000 mL/day unless contraindicated. There is no need to eliminate fiber from the diet; the client can eat whatever foods are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The client’s sexual activity may be affected, but it does not need to be diminished.
Question 13.
A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which additional signs and symptoms? Select all that apply.
(a) respiratory distress
(b) bleeding
(c) fluid and electrolyte imbalance
(d) weight gain
(e) infection
Answer:
(a) respiratory distress
(c) fluid and electrolyte imbalance
Explanation:
(a), (c). Ascites limit the movement of the diaphragm leading to respiratory distress. The fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure, precipitating the movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done
to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.
Question 14.
A client has 4,000 mL removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record your answer in whole numbers. ......................... kg.
Answer:
4kg. A liter of water weighs 1 kg. Therefore, the client should have a weight of 4 kg less than preprocedure weight.
Question 15.
Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider, the nurse should make which recommendation?
(a) “Do you want to request a computed tomography scan to rule out stroke?”
(b) “May we have a prescription for restraining this client?”
(c) “Shall I collect and send a urine sample for culture and sensitivity?”
(d) “Would you like a stat potassium level done?”
Answer:
(c) “Shall I collect and send a urine sample for culture and sensitivity?”
Explanation:
Sending a urine sample for culture and sensitivity is most warranted. An older adult often has confusion when experiencing a bladder infection. While stroke is always a concern, particularly in the older adult, the presenting information most supports a bladder infection and perhaps early-onset urosepsis. Restraining the client may be needed at some point in time, but finding the cause of the client’s new onset of confusion has greatest priority. Potassium is usually related to cardiac rhythm irritability rather than confusion.
Question 16.
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.
(a) age
(b) abdominal surgery
(c) gender
(d) diabetes mellitus
(e) weight
Answer:
(a) age
(b) abdominal surgery
(d) diabetes mellitus
Explanation:
(a), (b), (d). Known risk factors for sepsis include age (<1 year and >65 years old), chronic illness, and invasive procedures. Immunosuppression and mal nourishment are also risk factors. There is no correlation between gender or age and risk for sepsis. Nurses must be aware of risk factors and monitor clients at risk closely for any signs of sepsis.
Question 17.
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?
(a) her age
(b) three vaginal delivery pregnancies
(c) her job as a schoolteacher
(d) varicosities in her legs
Answer:
(b) three vaginal delivery pregnancies
Explanation:
Hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic constipation, and prolonged increased intraabdominal pressure, as associated with pregnancy and the strain of vaginal childbirth. Her job as a schoolteacher does not require prolonged sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.
Question 18.
The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which complication?
(a) hemorrhage
(b) rectal spasm
(c) urine retention
(d) constipation
Answer:
(a) hemorrhage
Explanation:
Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.
Question 19.
The nurse teaches the client who has had rectal surgery the proper timing for a cleansing sitz baths. What will indicate to the nurse that the client has understood when to take the sitz bath? The client will take the sitz bath:
(a) first thing each morning.
(b) as needed for discomfort.
(c) after a bowel movement.
(d) at bedtime.
Answer:
(c) after a bowel movement.
Explanation:
Adequate cleaning of the anal area is difficult but essential. After rectal surgery, sitz baths assist in this process, so the client should take a sitz bath after a bowel movement. Other times are dictated by client comfort.
Question 20.
A client has been placed on long-term sulfasalazine therapy for treatment of ulcerative colitis. The nurse should encourage the client to eat which foods to help avoid the nutrient deficiencies that may develop as a result of this medication?
(a) citrus fruits
(b) green, leafy vegetables
(c) eggs
(d) milk products
Answer:
(b) green, leafy vegetables
Explanation:
In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client can take folic acid supplements, but the nurse should also encourage the client to increase the intake of folic acid in the client’s diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs, and milk products are not good sources of folic acid.
Question 21.
A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids in drops per minute to infuse the fluids at the prescribed rate? Record your answer using a whole number............................. gtt/min.
Answer:
31 gtt/min. To administer IV fluids at 125 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse should use the formula:
125 mL/60 min x 15 gtt/1 mL = 31 gtt/min
Question 22.
Which goal for the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?
(a) promoting self-care and independence
(b) managing diarrhea
(c) maintaining adequate nutrition
(d) promoting rest and comfort
Answer:
(b) managing diarrhea
Explanation:
Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.
Question 23.
The client with an exacerbation of ulcerative colitis is to be on bed rest with bathroom privileges. What will indicate to the nurse that being on bed rest has had the desired outcome?
The client has:
(a) not fallen.
(b) slowed intestinal peristalsis.
(c) slept through the night.
(d) minimized stress.
Answer:
(b) slowed intestinal peristalsis.
Explanation:
Although bed rest does help conserve energy and promotes comfort, falling is not a risk, and its primary purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use strategies that will help the client manage the stress.
Question 24.
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?
(a) heart failure
(b) deep vein thrombosis
(c) hypokalemia
(d) hypocalcemia
Answer:
(c) hypokalemia
Explanation:
Excessive diarrhea causes significant depletion of the body’s stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.
Question 25.
A client who has ulcerative colitis says to the nurse, “I can’t take this anymore; I’m constantly in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with this.” Based on these comments, what judgment should the nurse make about what the client is experiencing?
(a) extreme fatigue
(b) disturbed thought
(c) a sense of isolation
(d) difficulty coping
Answer:
(d) difficulty coping
Explanation:
It is not uncommon for clients with ulcerative colitis to become apprehensive and have difficulty coping with the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.
Question 26.
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client?
(a) “Ulcerative colitis can be cured by the use of steroids.”
(b) “Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”
(c) “Long-term use of steroids will prolong periods of remission.”
(d) “The side effects of steroids outweigh their benefits to clients with ulcerative colitis.”
Answer:
(b) “Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”
Explanation:
Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.
Question 27.
A client who has ulcerative colitis has persistent diarrhea and has lost 12 lb [5.5 kg) since the exacerbation of the disease. Which approach will be most effective in helping the client meet nutritional needs?
(a) continuous enteral feedings
(b) following a high-calorie, high-protein diet
(c) total parenteral nutrition (TPN)
(d) eating six small meals a day
Answer:
(c) total parenteral nutrition (TPN)
Explanation:
Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the bowel. To maintain the client’s nutritional status, the client will be started on TPN. Enteral feedings or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein diet will worsen the client’s symptoms.
Question 28.
A client with ulcerative colitis is to take sul-fasalazine. Which instructions should the nurse give the client about taking this medication at home? Select all that apply.
(a) Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day.
(b) Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP).
(c) Stop taking the medication if the urine turns orange-yellow.
(d) Avoid activities that require alertness.
(e) If dose is missed, skip and continue with the next dose.
Answer:
(a) Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day.
(b) Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP).
(d) Avoid activities that require alertness.
Explanation:
(a), (b), (d). Sulfasalazine may cause dizziness, and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the HCP immediately.
Fluid intake should be sufficient to maintain a urine output of at least 1,200 to 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.
Question 29.
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? ....................... tablets.
Answer:
tablets. To administer 2 g sulfasalazine, the nurse will need to administer four tablets. The following formula is used to calculate the correct dosage:
The first step is to convert grams into milligrams:
1 g/1,000 mg = 2 gIX mg
X= 2,000 mg
Then, 2,000 mg/X tablets = 500 mg/1 tablet
X = 4 tablets
Question 30.
Which diet would be most appropriate for the client with ulcerative colitis?
(a) high-calorie, low-protein
(b) high-protein, low-residue
(c) low-fat, high-fiber
(d) low-sodium, high-carbohydrate
Answer:
(c) low-fat, high-fiber
Explanation:
Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.
Question 31.
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 review the client’s laboratory reports to determine which potential complication of the client’s symptoms?
(a) hyperalbuminemia
(b) thrombocytopenia
(c) hypokalemia
(d) hypercalcemia
Answer:
(c) hypokalemia
Explanation:
Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn’s disease; however, the client’s potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.
Question 32.
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 do first?
(a) Encourage the client to drink at least 1,000 mL/day.
(b) Provide parenteral rehydration therapy as prescribed.
(c) Turn and reposition every 2 hours.
(d) Monitor vital signs every shift.
Answer:
(b) Provide parenteral rehydration therapy as prescribed.
Explanation:
Initially, the extracellular fluid volume with isotonic IV fluids should be administered until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be >1,000 mL/day. Turning and repositioning the client at regular intervals aid in the prevention of skin breakdown, but it is first necessary to rehydrate this client.
Question 33.
Which is a priority focus of care for a client experiencing an exacerbation of Crohn’s disease?
(a) encouraging regular ambulation
(b) promoting bowel rest
(c) maintaining current weight
(d) decreasing episodes of rectal bleeding
Answer:
(b) promoting bowel rest
Explanation:
A priority goal of care during an acute exacerbation of Crohn’s disease is to promote bowel rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambula-tion is important, but the priority is bowel rest. The client will probably lose some weight during the acute phase of the illness. Diarrhea is nonbloody in Crohn’s disease, and episodes of rectal bleeding are not expected.
Question 34.
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which signs and symptoms? Select all that apply.
(a) projectile vomiting
(b) significant abdominal distention
(c) copious diarrhea
(d) rapid onset of dehydration
(e) increased bowel sounds
Answer:
(a) projectile vomiting
(d) rapid onset of dehydration
(e) increased bowel sounds
Explanation:
(a), (d), (e). Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly and produce persistent pain, and vomiting is less common. Clients with a large intestine obstruction may develop obstipation and significant abdominal distention.
Question 35.
A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The health care provider (HCP) has written the following prescriptions: for the client to be up ad lib, have narcotics for pain, have a nasogastric tube inserted if needed, and for IV, Ringer’s lactate, and hyperalimentation fluids. What should the nurse do in order of priority from first to last? All options must be used.
(a) Assist with ambulation to promote peristalsis.
(b) Insert a nasogastric tube.
(c) Administer IV Ringer’s lactate.
(d) Start an infusion of hyperalimentation fluids.
Answer:
(a) Assist with ambulation to promote peristalsis.
(c) Administer IV Ringer’s lactate.
(b) Insert a nasogastric tube.
(d) Start an infusion of hyperalimentation fluids.
Explanation:
(a), (c), (b), (d). The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. Next, the nurse should initiate IV fluid therapy to correct fluid and electrolyte imbalances (sodium and potassium) with Ringer’s lactate to correct interstitial fluid deficit. Nasogastric decompression of the GI tract to reduce gastric secretions and nasointestinal tubes may also be used as necessary. Lastly, hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection.
Question 36.
The health care provider (HCP) prescribes intestinal decompression with a Cantor tube for a client with an intestinal obstruction. What should the nurse evaluate in order to determine the effectiveness of intestinal decompression?
(a) Intestinal fluid and gas have been removed.
(b) The client has had a bowel movement.
(c) The client’s urinary output is adequate.
(d) The client can sit up without pain.
Answer:
(a) Intestinal fluid and gas have been removed.
Explanation:
Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube. These 6- to 10-foot (180- to 300-cm) tubes are passed into the small intestine to the obstruction. They remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel movement until the obstruction is removed. The pressure from the distended intestine should not obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the intestinal pressure will be less, these are not the primary indicators for successful intestinal decompression.
Question 37.
After insertion of a nasoenteric tube, the nurse should place the client in which position?
(a) supine
(b) right side-lying
(c) semi-Fowler’s
(d) upright in a bedside chair
Answer:
(b) right side-lying
Explanation:
The client is placed in a right side-lying position to facilitate movement of the mercury- weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops. Placing the client in the supine or semi-Fowler’s position or having the client sitting out of bed in a chair will not facilitate tube progression.
Question 38.
What should the nurse tell the client who is preparing for insertion of a nasoduodenal tube? Select all that apply.
(a) The nose and throat will be numbed with a viscous anesthetic.
(b) The tube will be placed at the bedside.
(c) X-rays with the use of a contrast dye will be used to verify placement.
(d) The client will be closely monitored for 30 minutes following the procedure.
(e) The tube will be taped to the nose.
Answer:
(a) The nose and throat will be numbed with a viscous anesthetic.
(c) X-rays with the use of a contrast dye will be used to verify placement.
(d) The client will be closely monitored for 30 minutes following the procedure.
(e) The tube will be taped to the nose.
Explanation:
(a), (c), (d), (e). A nasoduodenal tube is used primarily for feeding. The tube is inserted in endoscopy or radiology. Prior to insertion of the tube, the client’s nose and throat will be numbed with a viscous anesthetic such as lidocaine. The tube placement is verified by contrast X-rays, and the client is observed for 30 minutes after the insertion to be sure the client does not have an allergic reaction, puncture to the lung, or bleeding. The tube is taped to the nose.
Question 39.
The client with an intestinal obstruction continues to have acute pain even though the naso- enteric tube is patent and draining. What should the nurse do first?
(a) Reassure the client that the nasoenteric tube is functioning.
(b) Assess the client for signs of peritonitis.
(c) Administer an opioid as prescribed.
(d) Reposition the client on the left side.
Answer:
(b) Assess the client for signs of peritonitis.
Explanation:
The client’s pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.
Question 40.
Before abdominal surgery for an intestinal obstruction, the nurse monitors the client’s urine output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the client’s total intake and output over the last 24 hours and notes 2,000 mL of IV fluid for intake, 500 mL of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. How should the nurse interpret these findings?
(a) decreased renal function
(b) the nasogastric tube not draining well
(c) extension of the obstruction
(d) inadequate fluid replacement
Answer:
(d) inadequate fluid replacement
Explanation:
Considering that there is usually 1 L of insensible fluid loss, this client’s output exceeds his intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are concentrating urine in response to low circulating volume, as evidenced by a urine output of <30 mL/h. This indicates that increased fluid replacement is needed. Decreasing urine output can be a sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does not affect urine output. There are no data to suggest that the obstruction has worsened.
Question 41.
The nurse is teaching the client how to care for an ileostomy. The client asks the nurse how long to wear the pouch before changing it. What should the nurse tell the client?
(a) “The pouch is changed only when it leaks.”
(b) “You can wear the pouch for about 4 to 7 days.”
(c) “You should change the pouch every evening before bedtime.”
(d) “It depends on your activity level and your diet.”
Answer:
(b) “You can wear the pouch for about 4 to 7 days.”
Explanation:
Unless the pouch leaks, the client can wear the ileostomy pouch for about 4 to 7 days. If leakage occurs, it is important to promptly change the pouch to avoid skin irritation. It is not necessary to change the pouch daily or in the evening. Diet and activity typically do not affect the schedule for changing the pouch.
Question 42.
A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for the surgery?
(a) Include family members in preoperative teaching sessions.
(b) Encourage the client to ask questions about managing an ileostomy.
(c) Provide a brief, thorough explanation of all preoperative and postoperative procedures.
(d) Invite a member of the ostomy association to visit the client.
Answer:
(c) Provide a brief, thorough explanation of all preoperative and postoperative procedures.
Explanation:
Providing explanations of preoperative and postoperative procedures helps the client prepare and understand what to expect. It also provides an opportunity for the client to share concerns. Including family members in the teaching sessions is beneficial but does not focus on the client’s psychological preparation. Encouraging the client to ask questions about managing the ileostomy may be rushing the client psychologically into accepting the change in body image and function.
The client may need time to first handle the stress of surgery and then observe the care of the ileostomy by others before it is appropriate to begin discussing self-management. The nurse should gently explore whether the client is ready to ask questions about management throughout the hospitalization. The client should have the opportunity to express concerns and to agree to an ostomy association visitor before an invitation is extended.
Question 43.
The nurse is preparing a client for an ileostomy. Two weeks before the surgery, what should the nurse instruct the client to do?
(a) Stop taking drugs that will interfere with clotting.
(b) Follow a low-residue diet.
(c) Limit fluids to 1,000 mL/day.
(d) Report having a temperature above 99°F (37.2°C).
Answer:
(a) Stop taking drugs that will interfere with clotting.
Explanation:
The nurse should instruct the client to stop taking drugs that would interfere with clotting, such as aspirin or ibuprofen. The client should follow a high-fiber diet with increased fluids during the 2-week preoperative period. It is not necessary to limit fluids. The client does not need to report having a temperature above 99°F (37.2°C) to the health care provider (HCP) as this is within normal limits; however, if the temperature is higher, this could indicate an infection, and the client should notify the HCP.
Question 44.
Immediately after having surgery to create an ileostomy, which goal has the highest priority?
(a) providing relief from constipation
(b) assisting the client with self-care activities
(c) maintaining fluid and electrolyte balance
(d) minimizing odor formation
Answer:
(c) maintaining fluid and electrolyte balance
Explanation:
A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.
Question 45.
The client asks the nurse, “Is it really possible to lead a normal life with an ileostomy?” Which action by the nurse would be the most effective to address this question?
(a) Have the client talk with a member of the clergy about these concerns.
(b) Tell the client to worry about those concerns after surgery.
(c) Arrange for a person with an ostomy to visit the client preoperatively.
(d) Notify the surgeon of the client’s question.
Answer:
(c) Arrange for a person with an ostomy to visit the client preoperatively.
Explanation:
If the client agrees, having a visit by a person who has successfully adjusted to living with an ileostomy would be the most helpful measure. This would let the client actually see that typical activities of daily living can be pursued postoperatively. Someone who has felt some of the same concerns can answer the client’s questions. A visit from the clergy may be helpful to some clients but would not provide this client with the information sought. Disregarding the client’s concerns is not helpful. Although the health care provider (HCP) should know about the client’s concerns, this in itself will not reassure the client about life after an ileostomy.
Question 46.
Three weeks after the client has had an ileostomy, the nurse is following up with instructions about using a skin barrier around the stoma. How will the nurse determine that the client has been applying the skin barrier correctly?
(a) There is no odor from the stoma.
(b) The client is adequately hydrated.
(c) There is no skin irritation around the stoma.
(d) The client only changes the ostomy pouch once a day.
Answer:
(c) There is no skin irritation around the stoma.
Explanation:
Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet. The barrier does not affect the client’s hydration status, and the nurse can encourage the client to have an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.
Question 47.
What observation should the nurse instruct the client with an ileostomy to report immediately?
(a) passage of liquid stool from the stoma
(b) occasional presence of undigested food in the effluent
(c) absence of drainage from the ileostomy for 6 or more hours
(d) temperature of 99.8°F (37.7°C)
Answer:
(c) absence of drainage from the ileostomy for 6 or more hours
Explanation:
Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the health care provider (HCP) immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8°F (37.7°C) is not necessarily abnormal or a cause for concern.
Question 48.
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, “I’m upset because I know I won’t be able to have children now that I have an ileostomy.” Which response by the nurse is best?
(a) “Many women with ileostomies decide to adopt. Perhaps you could consider that option?”
(b) “Having an ileostomy doesn’t necessarily mean that you can’t bear children. Let’s talk about your concerns.”
(c) “I can understand your reasons for being upset. Having children must be important to you.”
(d) “I’m sure you will adjust to this situation with time. Try not to be too upset.”
Answer:
(b) “Having an ileostomy doesn’t necessarily mean that you can’t bear children. Let’s talk about your concerns.”
Explanation:
The fact that the client has an ileostomy does not necessarily mean that she cannot get pregnant and bear children. It may be recommended, however, that the number of pregnancies be limited. Women of childbearing age should be encouraged to discuss their concerns with their health care provider (HCP). Discussing their concerns about sexual functioning and pregnancy will help decrease fears and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her current fears may be based on erroneous understanding. Telling the client that she will adjust to the situation ignores her concerns.
Question 49.
Which statement about ileostomy care indicates that the client understands the discharge instructions?
(a) “I should be able to resume weight lifting in 2 weeks.”
(b) “I can return to work in 2 weeks.”
(c) “I need to drink at least 3,000 mL a day of fluid.”
(d) “I will need to avoid getting my stoma wet while bathing.”
Answer:
(c) “I need to drink at least 3,000 mL a day of fluid.”
Explanation:
To maintain an adequate fluid balance, the client needs to drink at least 3,000 mL/day. Heavy lifting should be avoided; the health care provider (HCP) will indicate when the client can participate in sports again. The client will not resume working as soon as 2 weeks after surgery. Water does not harm the stoma, so the client does not have to worry about getting it wet.
Question 50.
A client with a well-managed ileostomy has sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do?
(a) Take an antiemetic.
(b) Increase fluid intake to 3 L/day.
(c) Use 30 mL of milk of magnesia daily.
(d) Notify the health care provider (HCP).
Answer:
(d) Notify the health care provider (HCP).
Explanation:
Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an ileostomy are likely indications of an obstruction. It is imperative that the health care provider (HCP) examine the client immediately. Although the client is vomiting, the client should not take an antiemetic until the HCP has examined the client. If an obstruction is present, ingesting fluids or taking milk of magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is suspected.
Question 51.
The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse do first?
(a) Clean the insertion site and redress the area.
(b) Document assessment findings in the client’s chart.
(c) Request a prescription to obtain a culture of the drainage.
(d) Check the client’s temperature.
Answer:
(c) Request a prescription to obtain a culture of the drainage.
Explanation:
The nurse should first obtain a prescription to obtain a culture specimen. The presence of drainage is a potential indication of an infection and the catheter may need to be removed. A culture specimen should be obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter will be required in the presence of an infection, the nurse would not clean and redress the area. While the body temperature may increase indicating an infection, a culture needs to be obtained to identify the causative organism. After the culture report is obtained, the nurse should notify the health care provider (HCP) and document all assessments and client care activities in the client’s record.
Question 52.
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?
(a) Administer TPN through a nasogastric or gastrostomy tube.
(b) Handle TPN using strict aseptic technique.
(c) Auscultate for the presence of bowel sounds prior to administering TPN.
(d) Designate a peripheral IV site for TPN administration.
Answer:
(b) Handle TPN using strict aseptic technique.
Explanation:
TPN is a hypertonic, high-calorie, high- protein IV fluid that should be provided for clients who do not have functional gastrointestinal track motility, in order to better meet metabolic needs of the client and to support optimal nutrition and healing. TPN is prescribed once daily, based on the client’s current electrolyte and fluid balance, and must be handled with strict aseptic technique (due to the high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.
Question 53.
Using a sliding scale schedule, the nurse is preparing to administer an evening dose of regular insulin to a client who is receiving total parenteral nutrition (TPN). On which information should the nurse base the dosage?
(a) glucometer reading of the client’s glucose level obtained immediately before administering the insulin
(b) fasting blood glucose level obtained earlier in the day
(c) amount of TPN fluid the client has received since the last dose of insulin
(d) client’s dietary intake for the evening meal and snack
Answer:
(a) glucometer reading of the client’s glucose level obtained immediately before administering the insulin
Explanation:
When using a sliding scale insulin schedule, the nurse obtains a glucometer reading of the client’s blood glucose level immediately before giving the insulin and bases the dosage on those findings. The fasting blood glucose level obtained earlier in the day is not relevant to an evening sliding scale insulin dosage. The nurse cannot calculate insulin dosage by assessing the amount of TPN intake or dietary intake.
Question 54.
A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?
(a) Turn the client to the left side.
(b) Have the client exhale slowly and evenly.
(c) Elevate the head of the bed.
(d) Instruct the client to take a deep breath and hold it.
Answer:
(d) Instruct the client to take a deep breath and hold it.
Explanation:
The client should be asked to perform the Valsalva maneuver (take a deep breath and hold it) during insertion and removal of a CVAD. This increases central venous pressure during the procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insertion and removal. If not possible, supine position is sufficient for CVAD removal. The client should hold the breath, not exhale.
Question 55.
TPN is prescribed for a client with Crohn’s disease. What indicates to the nurse that the TPN has been effective? The client:
(a) has met nutritional needs.
(b) is not in metabolic acidosis.
(c) is hydrated.
(d) is in a negative nitrogen balance.
Answer:
(a) has met nutritional needs.
Explanation:
The goal of TPN is to meet the client’s nutritional needs. TPN is not used to treat metabolic acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen balance.
Question 56.
A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client’s ability to metabolize the TPN solution adequately by monitoring the client for which sign? Select all that apply.
(a) tachycardia
(b) hypertension
(c) elevated blood urea nitrogen concentration
(d) hyperglycemia
Answer:
(d) hyperglycemia
Explanation:
During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client’s ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.
Question 57.
A client is receiving TPN administered through a central line. What should the nurse do to prevent complications associated with this infusion?
(a) Use aseptic technique for dressing changes.
(b) Secure all connections of the system.
(c) Keep the client on strict bed rest.
(d) Cover the insertion site with a moisture-proof dressing.
Answer:
(a) Use aseptic technique for dressing changes.
(b) Secure all connections of the system.
(d) Cover the insertion site with a moisture-proof dressing.
Explanation:
(a), (b), (d). Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system must be secure. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.
Question 58.
The nurse administers fat emulsion solution during TPN to a malnourished client. What should the nurse tell the client about the purpose of this solution?
Fat emulsion solution:
(a) provides essential fatty acids.
(b) adds extra carbohydrates.
(c) promotes effective metabolism of glucose.
(d) maintains a normal body weight.
Answer:
(a) provides essential fatty acids.
Explanation:
The administration of fat emulsion solution provides additional calories and essential fatty acids to meet the body’s energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs of the client, fatty acids do not necessarily help a client maintain normal body weight.
Question 59.
A client is receiving TPN therapy. Which finding should the nurse report to the health care provider?
(a) glycosuria
(b) a 1- to 2-lb (0.45- to 0.9-kg) weight gain
(c) decreased appetite
(d) elevated temperature
Answer:
(d) elevated temperature
Explanation:
An elevated temperature can be an indication of an infection at the insertion site or in the catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early signs of complications. Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client’s nutritional status improves. Some clients experience a decreased appetite during TPN therapy.
Question 60.
Which adverse effect occurs when there is too rapid an infusion of TPN solution?
(a) negative nitrogen balance
(b) circulatory overload
(c) hypoglycemia
(d) hypokalemia
Answer:
(b) circulatory overload
Explanation:
Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.
Question 61.
Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply.
(a) bran cereal
(b) broccoli
(c) tomato juice
(d) navy beans
(e) cheese
Answer:
(a) bran cereal
(b) broccoli
(d) navy beans
Explanation:
(a), (b), (d). Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.
Question 62.
When a client has an acute attack of diverticulitis, what should the nurse do first?
(a) Prepare the client for a colonoscopy.
(b) Encourage the client to eat a high-fiber diet.
(c) Assess the client for signs of peritonitis.
(d) Encourage the client to drink a glass of water every 2 hours.
Answer:
(c) Assess the client for signs of peritonitis.
Explanation:
The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation; bowel obstruction; ureteral obstruction; and bleeding. A computed tomography scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.
Question 63.
The nurse should teach the client with diverticulitis to integrate which measure into a daily routine at home?
(a) using enemas to relieve constipation
(b) decreasing fluid intake to increase the formed consistency of the stool
(c) eating a high-fiber diet when symptomatic with diverticulitis
(d) refraining from straining and lifting activities
Answer:
(d) refraining from straining and lifting activities
Explanation:
Clients with diverticular disease should refrain from any activities, such as lifting, straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is present.
Question 64.
After instructing a client with diverticulosis about appropriate self-care activities, which comment by the client indicates effective teaching? Select all that apply.
(a) “With careful attention to my diet, my diver ticulosis can be cured.”
(b) “Using a cathartic laxative weekly is okay to control bowel movements.”
(c) “I should follow a diet that is high in fiber.”
(d) “It is important for me to drink at least 2,000 mL of fluid every day.”
(e) “I should exercise regularly.”
Answer:
(b) “Using a cathartic laxative weekly is okay to control bowel movements.”
(d) “It is important for me to drink at least 2,000 mL of fluid every day.”
(e) “I should exercise regularly.”
Explanation:
(b), (d), (e). Clients who have diverticulosis should be instructed to maintain a diet high in fiber and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/day. Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of cathartic laxatives. Bulk laxa-tives and stool softeners may be helpful to maintain regularity and decrease straining.
Question 65.
A client with diverticular disease is receiving psyllium hydrophilic mucilloid. Which response from the client indicates to the nurse that the drug is having the intended effect?
(a) “I can pass stool without cramping.”
(b) “I have occasional diarrhea.”
(c) “My stool is firm.”
(d) “I don’t expel gas.”
Answer:
(a) “I can pass stool without cramping.”
Explanation:
Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium hydrophilic mucilloid. Fiber decreases the intraluminal pressure and makes it easier for stool to pass through the colon. Bulk laxatives do not manage diarrhea or relieve gas formation. The stool should remain soft and easy to expel.
Question 66.
A client with diverticulitis has developed peritonitis following diverticular rupture. When assessing the client, what should the nurse do? Select all that apply.
(a) Percuss the abdomen to note tympany.
(b) Percuss the liver to note lack of dullness.
(c) Monitor the vital signs for fever.
(d) Assess presence of excessive thirst.
(e) Auscultate bowel sounds to note frequency.
Answer:
(a) Percuss the abdomen to note tympany.
(b) Percuss the liver to note lack of dullness.
(c) Monitor the vital signs for fever.
(e) Auscultate bowel sounds to note frequency.
Explanation:
(a), (b), (c), (e). Percussion will show resonance and tympany indicating paralytic ileus. Lack of liver dullness may indicate free air in the abdomen. The client with peritonitis will have fever, tachypnea, and tachycardia. The abdomen becomes rigid with rebound tenderness, and there will be absent bowel sounds. The client will not demonstrate excessive thirst but may have anorexia, nausea, and vomiting as peristalsis decreases.
Question 67.
A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. What should the nurse do to provide wound care?
(a) Remove the dressing and leave the incision open to air.
(b) Remove the drain if wound drainage is minimal.
(c) Gently irrigate the drain to remove exudate.
(d) Clean the area around the drain moving away from the drain.
Answer:
(d) Clean the area around the drain moving away from the drain.
Explanation:
The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.
Question 68.
An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery?
(a) Place the client in semi-Fowler’s position with the knees to the chest.
(b) Apply moist heat to the abdomen.
(c) Teach client to massage the painful area.
(d) Provide distraction with music.
Answer:
(a) Place the client in semi-Fowler’s position with the knees to the chest.
Explanation:
Appendicitis typically begins with periumbilical pain followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney’s point (located halfway between the umbilicus and the right iliac crest). To relieve pain prior to surgery, the nurse assists the client to a comfortable position with the knees drawn to the chest and the head of the bed slightly elevated.
The nurse may also administer analgesics and ice packs, if prescribed; heat is avoided as heat may precipitate rupture of the appendix. The abdomen is not palpated or massaged more than neces-sary to avoid increasing the pain. Distraction with music may be helpful, but positioning, using ice packs, and analgesics are most effective.
Question 69.
The nurse is instructing a client about postoperative care following a laparoscopic appendectomy. What information should the nurse include in the teaching plan? Select all that apply.
(a) “Nausea, gas, and diarrhea are normal for several days.”
(b) “You can return to work in 1 to 3 weeks.”
(c) “Follow a low-residue diet until the incision has healed.”
(d) “Take a tub bath to relieve abdominal swelling.”
(e) “You can drive when you are not taking pain medications.”
Answer:
(a) “Nausea, gas, and diarrhea are normal for several days.”
(b) “You can return to work in 1 to 3 weeks.”
(e) “You can drive when you are not taking pain medications.”
Explanation:
(a), (b), (e). The nurse should instruct the client that nausea, abdominal distention from gas, and diarrhea are normal following an appendectomy. The client will be able to return to work and usual activities in 1 to 3 weeks. The client does not need to follow a low-residue diet but may prefer a bland diet if the client has nausea or an upset stomach. The client can drive if not taking pain medication. The client should not take a tub bath until the incision has healed.
Question 70.
A client who had an open appendectomy for a perforated appendix has an incision secured with adhesive strips. What instruction should the nurse give the client about caring for the incision?
(a) Remove the adhesive strips to cleanse the area.
(b) Cover the adhesive strips with a dressing to protect the area.
(c) Leave the adhesive strips in place until they fall off.
(d) Place plastic wrap over the incision when taking a bath.
Answer:
(c) Leave the adhesive strips in place until they fall off.
Explanation:
The adhesive strips should stay in place until they fall off. The client should not remove them to cleanse the area. It is not necessary to place an additional dressing over the adhesive strips. The client should not take a tub bath until the incision has healed.
Question 71.
A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which complication?
(a) peritonitis
(b) incarcerated hernia
(c) strangulated hernia
(d) intestinal perforation
Answer:
(c) strangulated hernia
Explanation:
The symptoms are indicative of a strangulated hernia. In a strangulated hernia, the hernia cannot be reduced back into the abdominal cavity. The intestinal lumen and the blood supply to the intestine are obstructed, causing an acute intestinal obstruction. Without immediate intervention, necrosis and gangrene may develop. Surgery is required to release the strangulation.
Although many of these signs and symptoms are present with peritonitis or perforated bowel, abdominal rigidity, a cardinal sign of peritonitis and perforated bowel, is not mentioned. Therefore, the nurse would not immediately suspect these conditions. An incarcerated hernia refers to a hernia that is irreducible but has not necessarily resulted in an obstruction.
Question 72.
The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. What information should the nurse give the client?
(a) Cough and deep breathe every 2 hours.
(b) Apply warm, moist heat to the groin.
(c) Sneeze with mouth closed.
(d) Avoid lifting items weighing >5 lb (2.3 kg).
Answer:
(d) Avoid lifting items weighing >5 lb (2.3 kg).
Explanation:
The client is instructed to avoid lifting items heavier than 5 lb (2.3 kg) for 4 to 6 weeks following hernia repair. The client continues to take deep breaths and expand the lungs but is instructed to avoid coughing. Ice, rather than heat, is used to reduce scrotal swelling. The client is instructed to sneeze with the mouth open to avoid sudden stress on the sutures.
Question 73.
After an inguinal herniorrhaphy, the nurse should assess the male client carefully for which complication?
(a) hypostatic pneumonia
(b) deep vein thrombosis
(c) paralytic ileus
(d) urine retention
Answer:
(d) urine retention
Explanation:
The most common complication after an inguinal hernia repair is the inability to void, especially in men. The nurse should evaluate the client carefully for urine retention. Hypostatic pneumonia, deep vein thrombosis, and paralytic ileus are potential postoperative problems with any surgical client but are not as likely to occur after an inguinal hernia repair as is urine retention.
Question 74.
A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety?
(a) Discontinue the TPN infusion.
(b) Start an IV infusion of normal saline.
(c) Administer PRBCs in the same IV as the TPN.
(d) Wait until the TPN infusion is completed, and use the same IV line to infuse the PRBCs.
Answer:
(b) Start an IV infusion of normal saline.
Explanation:
The nurse administers the PRBCs using a separate infusion line and appropriate tubing, with normal saline as the priming solution. It is not necessary to discontinue the TPN infusion or wait until the TPN infusion is completed.
Question 75.
The nurse is assigning clients for the evening shift. Which clients are appropriate for the nurse to assign to a licensed practical/vocational nurse (LPN/VN) to provide client care? Select all that apply.
The client with:
(a) Crohn’s disease who is receiving total parenteral nutrition (TPN).
(b) an inguinal hernia repair surgery 3 hours ago; vital signs are stable.
(c) an intestinal obstruction that needs a Cantor tube inserted.
(d) diverticulitis who needs teaching about take-home medications.
(e) an exacerbation of ulcerative colitis who is ambulatory.
Answer:
(b) an inguinal hernia repair surgery 3 hours ago; vital signs are stable.
(e) an exacerbation of ulcerative colitis who is ambulatory.
Explanation:
The nurse should consider the client's needs and scope of practice when assigning staff to provide care. The client who is recovering from inguinal hernia repair surgery and the client who is experiencing an exacerbation of ulcerative colitis are appropriate clients to assign to an LPN/VN as the care they require falls within the scope of practice for an LPN or a VN. It is not within the scope of practice for the LPN/VN to administer TPN, insert nasoenteric tubes, or provide client teaching related to medications.
Question 76.
When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply.
(a) assessing the client’s bowel sounds
(b) providing skin care following bowel movements
(c) evaluating the client’s response to antidiarrheal medications
(d) maintaining intake and output records
(e) obtaining the client’s weight
Answer:
(b) providing skin care following bowel movements
(d) maintaining intake and output records
(e) obtaining the client’s weight
Explanation:
(b), (d), (d), (e). The nurse can delegate the following basic care activities to the UAP providing skin care following bowel movements, maintaining intake and output records, and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse (RN) activities that cannot be delegated.
Question 77.
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 10(a)5°F (38.6°C), blood pressure is 92/36 mm Hg (MAP 55 mm Hg), and heart rate is 114 bpm with SpO2 of 88% on oxygen at 2 L/min per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?
(a) Obtain stat portable chest X-ray.
(b) Administer vancomycin intravenously.
(c) Draw blood cultures.
(d) Insert an indwelling urinary catheter.
Answer:
(c) Draw blood cultures.
Explanation:
This client has signs and symptoms of severe sepsis. Blood cultures should be drawn prior to administering the antibiotic (vancomycin), and the antibiotics should be administered within the first 45 minutes after recognition of these signs in order to try to prevent septic shock. Obtaining a chest X-ray and inserting a urinary catheter to accurately measure intake and output are also important actions but are not first priority for this client.
Question 78.
The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply.
(a) Wear a particulate respirator.
(b) Wear sterile gloves when providing care.
(c) Cleanse hands with alcohol-based hand sanitizer.
(d) Wash hands with soap and water.
(e) Wear a protective gown when in the client’s room.
Answer:
(d) Wash hands with soap and water.
(e) Wear a protective gown when in the client’s room.
Explanation:
(d), (e). difficile is an organism that has developed very resistant and highly morbid strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean gloves may be worn.
Question 79.
The nurse discovers that a client’s TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem?
(a) Readjust the solution to infuse the desired amount.
(b) Continue the infusion at the current rate, but run the next bottle at an increased rate.
(c) Double the infusion rate for 2 hours.
(d) Notify the health care provider (HCP).
Answer:
(d) Notify the health care provider (HCP).
Explanation:
When TPN fluids are infused too rapidly or too slowly, the HCP should be notified. TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without a written prescription from the HCP. Significant alterations in rate (10% increase or decrease) can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much glucose entering the system
Question 80.
The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client’s medication box, which is located inside of the client’s room.
The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. What should the nurse do next?
(a) Administer the medication to maintain blood levels of the drug.
(b) Ask another registered nurse to verify that the capsule is ampicillin.
(c) Contact the pharmacy to bring a properly labeled medication.
(d) Notify the unit manager to report the problem.
Answer:
(c) Contact the pharmacy to bring a properly labeled medication.
Explanation:
The nurse should contact the pharmacy directly and request that a properly labeled medication be provided. The nurse should not administer any drug that is not properly labeled, even if the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at this point because the client needs to receive the antibiotic as soon as possible.
Question 81.
On the 2nd day following an abdominal- perineal resection, the nurse notes that the wound edges are not approximated and one-half of the incision has torn apart. What should the nurse do first?
(a) Flush the wound with sterile water.
(b) Apply an abdominal binder.
(c) Cover the wound with a sterile dressing moistened with normal saline.
(d) Apply strips of tape.
Answer:
(c) Cover the wound with a sterile dressing moistened with normal saline.
Explanation:
When dehiscence occurs, the nurse should immediately cover the wound with a sterile dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured in surgery. Later, after the sutures are removed, additional support may be provided to the incision by applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may also be utilized for additional support.
Question 82.
A client has received numerous different antibiotics and now is experiencing diarrhea. What type of precautions should the nurse institute?
(a) airborne precautions
(b) contact precautions
(c) droplet precautions
(d) standard precautions
Answer:
(b) contact precautions
Explanation:
The nurse should initiate contact precautions to prevent blood borne infection through percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp objects are handled. Airborne precautions are required for clients with presumed or proven pulmonary tuberculosis, chickenpox, or other airborne pathogens.
Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic- resistant organisms or Clostridium difficile. Droplet precautions are used for organisms such as influenza or Neisseria meningitides that can be transmitted by close respiratory or mucous membrane contact with respiratory secretions. Standard precautions include handwashing and use of a mask and gown.
Question 83.
The health care provider has prescribed ciprofloxacin for a client who takes warfarin. What should the nurse instruct the client to do? Select all that apply.
(a) Take the medication with food.
(b) Avoid exposure to sunlight.
(c) Eliminate caffeine from the diet.
(d) Report unusual bleeding.
(e) Increase fluid intake to 3,000 mL/day.
Answer:
(a) Take the medication with food.
(d) Report unusual bleeding.
Explanation:
(a), (d). A black box warning for ciprofloxacin is that ciprofloxacin may increase the anticoagulant effects of warfarin. The nurse should instruct the client to report increased bleeding and to monitor the prothrombin time and the international normalized ratio closely. The client can take the drug with or without food.
Although there is a drug-food interaction and taking ciprofloxacin may increase the stimulatory effect of caffeine, the client does not need to eliminate caffeine but should report signs of stimulant effect. Ciprofloxacin may cause photosensitivity reactions; the nurse must advise the client to avoid excessive sunlight or artificial ultraviolet light during therapy. Clients must be advised not to crush, split, or chew the extended-release tablets.
Question 84.
The nurse has completed the discharge process for a client, but the client has turned on the nurse call light, and on assessment, the nurse notices the client has indigestion, shortness of breath, and is diaphoretic and anxious. The cli-ent’s blood pressure and heart rate are elevated. The nurse notifies the health care provider who tells the nurse to discharge the client. The nurse explains the situation again, but the health care provider hangs up. What should the nurse do next?
(a) Contact the nurse navigator to arrange for home health services.
(b) Notify the charge nurse and request a second opinion.
(c) Reassure the client that the health care provider is aware of the client’s situation and discharge the client.
(d) Notify the risk manager of the client’s status prior to discharge.
Answer:
(b) Notify the charge nurse and request a second opinion.
Explanation:
A reasonable and prudent nurse would act as the client’s advocate and question a prescription that places a client at risk. Consulting the charge nurse to assess the client, shifts responsibility to the next in command with higher authority and will validate the nurse’s assessment. The client should not be discharged until the client is stable. While the client may require home health services, the client is not ready for discharge at this time. It is not appropriate to notify the risk manager at this time, and if necessary would be the role of the charge nurse or nurse manager.
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