Altered Nutrition/Elimination

Created by eRiN523 

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1. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse?
a. The patient has been vomiting several times a day for the last 4 days.
b. The patient is lethargic and difficult to arouse.
c. The patient's chart indicates a recent resection of the small intestine.
d. The patient has taken only sips of water.

Answer: B
Rationale: A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

Cognitive Level: Application Text Reference: p. 991
Nursing Process: Assessment NCLEX: Physiological Integrity

2. A patient with deep partial-thickness (second-degree) burns over 70% of the body experiences severe pain associated with nausea and occasional vomiting during dressing changes. To promote relief of the patient's nausea and vomiting, the nurse should
a. administer the prescribed morphine sulfate before dressing changes.
b. avoid performing dressing changes close to the patient's mealtimes.
c. keep the patient NPO for 2 hours before and after dressing changes.
d. give the ordered prochlorperazine (Compazine) before dressing changes.

Answer: A
Rationale: Because the patient's nausea and vomiting are associated with severe pain, it is likely that they are precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times should also be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

Cognitive Level: Application Text Reference: p. 991
Nursing Process: Implementation NCLEX: Physiological Integrity

3. Which of these nursing actions should the RN working in the emergency department delegate to a nursing assistant who is helping with the care of a patient who has been admitted with nausea and vomiting?
a. Assess for signs of dehydration.
b. Ask the patient what precipitated the nausea.
c. Auscultate the bowel sounds.
d. Assist the patient with oral care after vomiting.

Answer: D
Rationale: Oral care is included in nursing assistant education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

Cognitive Level: Application Text Reference: pp. 992-995
Nursing Process: Implementation NCLEX: Physiological Integrity

4. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient?
a. A glass of orange juice
b. A bowl of hot chicken broth
c. A dish of lemon gelatin
d. A cup of coffee with cream

Answer: C
Rationale: Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

Cognitive Level: Comprehension Text Reference: pp. 992, 995
Nursing Process: Implementation NCLEX: Physiological Integrity

5. All the following orders are received for a patient who has been admitted with dehydration after 3 days of nausea and vomiting. Which order will the nurse act on first?
a. Provide oral care with moistened swabs.
b. Infuse normal saline at 250 ml/hr.
c. Insert a 16-gauge nasogastric (NG) tube.
d. Administer IV ondansetron (Zofran).

Answer: B
Rationale: Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

Cognitive Level: Application Text Reference: pp. 993-994
Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient who is receiving chemotherapy develops a Candida albicans oral infection. The nurse will anticipate the need for
a. hydrogen peroxide rinses.
b. administration of nystatin (Mycostatin) oral tablets.
c. the use of antiviral agents.
d. referral to a dentist for professional tooth cleaning.

Answer: B
Rationale: Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

Cognitive Level: Application Text Reference: p. 1000
Nursing Process: Planning NCLEX: Physiological Integrity

7. When the nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer, which finding will be of most concern?
a. A 3-mm ulcer on the floor of the mouth
b. A red, velvety patch on the buccal mucosa
c. White, curdlike plaques on the back of the tongue
d. Painful blisters at the border of the lips

Answer: B
Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (greater than 50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (aphthous stomatitis, oral candidiasis, and herpes simplex).

Cognitive Level: Comprehension Text Reference: p. 1001
Nursing Process: Assessment NCLEX: Physiological Integrity

8. The nurse is admitting a patient who has been diagnosed with squamous cell carcinoma of the buccal mucosa. When interviewing the patient for the health history, the nurse will ask about
a. any use of tobacco by the patient.
b. any history of streptococcal throat infection.
c. chronic overexposure to the sun.
d. recurrent herpes simplex (HSV) infections.

Answer: A
Rationale: Tobacco use greatly increases the risk for oral cancer. History of acute infections such as strep throat is not a risk factor for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus infection (HPV) infection may be associated with increased risk, but HSV infection is not a risk factor for oral cancer.

Cognitive Level: Comprehension Text Reference: pp. 1001-1002
Nursing Process: Assessment NCLEX: Physiological Integrity

9. A patient with oral squamous cell carcinoma is transferred to the postoperative surgical unit after a hemiglossectomy and radical neck procedure. When planning care the nurse will anticipate the need to
a. insert a long-term central venous catheter for parenteral nutrition.
b. use an alphabet board to assist the patient with communication.
c. administer chemotherapy starting the first postoperative day.
d. reinforce pressure dressings at the surgical incision.

Answer: B
Rationale: The patient will have a tracheostomy after having a radical neck procedure, and the nurse should plan ways to allow the patient to communicate. IV fluids (but not parenteral nutrition) are given for 24 to 48 hours, followed by enteral feedings. Chemotherapy is not started until after surgical wounds have healed. Pressure dressings are not used because they could obstruct the patient's airway.

Cognitive Level: Application Text Reference: p. 1003
Nursing Process: Planning NCLEX: Physiological Integrity

10. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?
a. "I take antacids between meals and at bedtime each night."
b. "I quit smoking several years ago, but I still chew a lot of gum."
c. "I sleep with the head of the bed elevated on 4-inch blocks."
d. "I eat small meals throughout the day and have a bedtime snack."

Answer: D
Rationale: GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

Cognitive Level: Application Text Reference: p. 1005
Nursing Process: Evaluation NCLEX: Physiological Integrity

11. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of GERD. The nurse will plan to do frequent assessment of the patient's
a. bowel sounds.
b. breath sounds.
c. apical pulse.
d. abdominal girth.

Answer: B
Rationale: Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Cognitive Level: Application Text Reference: p. 1005
Nursing Process: Assessment NCLEX: Physiological Integrity

12. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug
a. reduces the reflux of gastric acid by increasing the rate of gastric emptying.
b. coats and protects the lining of the stomach and esophagus from gastric acid.
c. treats gastroesophageal reflux disease by decreasing stomach acid production.
d. neutralizes stomach acid and provides relief of symptoms in a few minutes.

Answer: C
Rationale: The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

Cognitive Level: Comprehension Text Reference: pp. 998, 1006
Nursing Process: Implementation NCLEX: Physiological Integrity

13. After the nurse teaches a patient with GERD about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective?
a. Chocolate pudding
b. Glass of low-fat milk
c. Peanut butter sandwich
d. Cherry gelatin and fruit

Answer: D
Rationale: Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

Cognitive Level: Application Text Reference: p. 1005
Nursing Process: Evaluation NCLEX: Physiological Integrity

14. Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately?
a. The patient has absent breath sounds throughout the left lung.
b. The patient complains of 6/10 (of a 0-10 scale) abdominal pain.
c. The patient has decreased bowel sounds in all four quadrants.
d. The patient is experiencing intermittent waves of nausea.

Answer: A
Rationale: Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea should also be addressed but are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

Cognitive Level: Application Text Reference: p. 1008
Nursing Process: Assessment NCLEX: Physiological Integrity

15. A patient who has recently been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about
a. endoscopy procedures.
b. barium swallow.
c. radionuclide tests.
d. proton pump inhibitors.

Answer: D
Rationale: Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Cognitive Level: Application Text Reference: p. 1005
Nursing Process: Planning NCLEX: Physiological Integrity

16. A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, "I know that my chances are not very good, but I do not feel ready to die yet." Which response by the nurse is most appropriate?
a. "You may have quite a few years to live still left."
b. "Having this new diagnosis must be very hard for you."
c. "Thinking about dying will only make you feel worse."
d. "It is important that you be realistic about your prognosis."

Answer: B
Rationale: This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a 20% 5-year survival rate, so the response "You may have quite a few years to live still yet" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. And the response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

Cognitive Level: Application Text Reference: p. 1011
Nursing Process: Implementation NCLEX: Psychosocial Integrity

17. Which information will the nurse include when teaching a patient with newly diagnosed GERD?
a. "Peppermint tea may be helpful in reducing your symptoms."
b. "You will need to keep the head of your bed elevated on blocks."
c. "You should avoid eating between meals to reduce acid secretion."
d. "Vigorous physical activities may increase the incidence of reflux."

Answer: B
Rationale: Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distension. There is no need to make changes in physical activities because of GERD.

Cognitive Level: Application Text Reference: p. 1007
Nursing Process: Implementation NCLEX: Physiological Integrity

18. A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing actions should be included in the postoperative plan of care?
a. Elevate the head of the bed to at least 30 degrees.
b. Reposition NG tube if drainage stops or decreases.
c. Notify doctor immediately about bloody NG drainage.
d. Start oral fluids when patient has active bowel sounds.

Answer: A
Rationale: Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

Cognitive Level: Application Text Reference: p. 1011
Nursing Process: Planning NCLEX: Physiological Integrity

19. The nurse will plan to teach the patient with newly diagnosed achalasia that
a. drinking fluids with meals should be avoided.
b. lying down and resting after meals is recommended.
c. a liquid or blenderized diet will be necessary.
d. endoscopic procedures may be used for treatment.

Answer: D
Rationale: Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying.

Cognitive Level: Application Text Reference: p. 1012
Nursing Process: Planning NCLEX: Physiological Integrity

20. A patient who is nauseated and vomiting up blood streaked fluid is admitted to the hospital with acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about
a. frequency of nonsteroidal antiinflammatory drug (NSAID) use.
b. family history of gastric problems.
c. recent weight gain or loss.
d. the amount of fat in the diet.

Answer: A
Rationale: Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

Cognitive Level: Application Text Reference: p. 1013
Nursing Process: Assessment NCLEX: Physiological Integrity

21. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states,
a. "These injections will decrease my risk for developing stomach cancer."
b. "These injections will increase the hydrochloric acid in my stomach."
c. "The cobalamin injections need to be taken until my inflamed stomach heals."
d. "The cobalamin injections will prevent me from becoming anemic."

Answer: D
Rationale: Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin.

Cognitive Level: Application Text Reference: p. 1014
Nursing Process: Evaluation NCLEX: Physiological Integrity

22. A patient with chronic gastritis associated with the presence of Helicobacter pylori is treated with triple-drug therapy. The nurse explains to the patient that the drugs commonly included in this regimen include
a. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix).
b. amoxicillin (Amoxil ), clarithromycin (Biaxin), and omeprazole (Prilosec).
c. sucralfate (Carafate), nystatin (Mycostatin), and bismuth subsalicylate (Pepto-Bismol).
d. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).

Answer: B
Rationale: The drugs used in triple-drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

Cognitive Level: Comprehension Text Reference: p. 1014
Nursing Process: Implementation NCLEX: Physiological Integrity

23. The health care provider orders insertion of a 20-gauge orogastric tube for a patient experiencing massive hematemesis. As the nurse inserts the tube, resistance is met in advancing the tube. The appropriate action by the nurse is to
a. ask the patient to hyperextend the neck.
b. stop and notify the health care provider of the resistance.
c. inject additional lubricant through the tube.
d. withdraw the tube a few inches and then reinsert.

Answer: B
Rationale: No tube should be advanced against resistance because of the risk for mucosal damage or perforation of the esophagus. Hyperextension of the neck will increase the likelihood of insertion into the trachea. Because the tube may be in the trachea, injection of lubricant may cause aspiration. Withdrawal and reinsertion of the tube will increase the risk for mucosal damage or perforation.

Cognitive Level: Application Text Reference: p. 996
Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for
a. endoscopy.
b. angiography.
c. gastric analysis testing.
d. barium contrast studies.

Answer: A
Rationale: Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy can not be done, because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding.

Cognitive Level: Application Text Reference: p. 997
Nursing Process: Planning NCLEX: Physiological Integrity

25. A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse accomplish first?
a. Measuring the quantity of any emesis
b. Checking the level of consciousness
c. Auscultating the chest for breath sounds
d. Taking the blood pressure (BP) and pulse

Answer: D
Rationale: The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute GI bleeding; BP and pulse are the best indicators of these complications. The other information is also important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

Cognitive Level: Application Text Reference: p. 997
Nursing Process: Assessment NCLEX: Physiological Integrity

26. The health care provider orders IV vasopressin (Pitressin) to be administered to a patient with esophageal bleeding. During administration of the drug, the nurse will monitor the patient for
a. polyuria.
b. metabolic alkalosis.
c. intention tremors.
d. chest pain.

Answer: D
Rationale: Vasopressin decreases coronary artery perfusion and may cause coronary ischemia. The other symptoms are not adverse effects associated with vasopressin.

Cognitive Level: Application Text Reference: p. 997
Nursing Process: Evaluation NCLEX: Physiological Integrity

27. The health care provider orders IV ranitidine (Zantac) for a patient with an acute exacerbation of chronic peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include?
a. "Ranitidine constricts the blood vessels in the stomach and decreases bleeding."
b. "Ranitidine decreases secretion of gastric acid."
c. "Ranitidine neutralizes the acid in the stomach."
d. "Ranitidine covers the ulcer with a protective material which promotes healing."

Answer: B
Rationale: Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

Cognitive Level: Application Text Reference: pp. 998, 1019
Nursing Process: Implementation NCLEX: Physiological Integrity

28. The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will
a. decrease the risk for nausea and vomiting.
b. prevent aspiration of gastric contents.
c. inhibit the development of stress ulcers.
d. lower the chance for H. pylori infection.

Answer: C
Rationale: Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

Cognitive Level: Application Text Reference: pp. 996, 998, 1017, 1019
Nursing Process: Implementation NCLEX: Physiological Integrity

29. A patient with a bleeding duodenal ulcer has an NG tube in place, and the health care provider orders 30 ml of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse
a. periodically aspirates and tests gastric pH.
b. measures the amount of residual stomach contents hourly.
c. monitors arterial blood gas values on a daily basis.
d. checks each stool for the presence of occult blood.

Answer: A
Rationale: The purpose for antacids is to increase gastric pH; checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper GI bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

Cognitive Level: Application Text Reference: p. 1020
Nursing Process: Evaluation NCLEX: Physiological Integrity

30. A patient with a peptic ulcer who has an NG tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?
a. Irrigate the NG tube.
b. Obtain the vital signs.
c. Give the ordered antacid.
d. Listen for bowel sounds.

Answer: B
Rationale: The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that the nurse should take.

Cognitive Level: Application Text Reference: pp. 1023-1024
Nursing Process: Implementation NCLEX: Physiological Integrity

31. Twelve hours after undergoing a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer, a patient complains of increasing abdominal pain. The nursing assessment reveals an absence of bowel sounds and 200 ml of bright red NG drainage in the last hour. The most appropriate action by the nurse at this time is to
a. notify the health care provider.
b. irrigate the NG tube.
c. administer the ordered morphine sulfate.
d. continue to monitor the NG drainage.

Answer: A
Rationale: Increased pain and 200 ml of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.

Cognitive Level: Application Text Reference: p. 1027
Nursing Process: Implementation NCLEX: Physiological Integrity

32. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective?
a. "I will need to choose foods that are low in fat and high in carbohydrate."
b. "I will try to drink liquids along with my meals."
c. "Vitamin injections may be needed to prevent problems with anemia."
d. "The surgery has cured my peptic ulcer disease."

Answer: C
Rationale: Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin injections. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Peptic ulcer disease (PUD) is a chronic problem, and the patient will need to continue lifestyle changes and perhaps medications to prevent recurrence.

Cognitive Level: Application Text Reference: p. 1027
Nursing Process: Evaluation NCLEX: Physiological Integrity

33. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations, with an urge to defecate about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to
a. increase the amount of fluid intake with meals.
b. lie down for about 30 minutes after eating.
c. drink sugared fluids or eat candy after each meal.
d. choose foods that are high in carbohydrates.

Answer: B
Rationale: The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

Cognitive Level: Application Text Reference: p. 1027
Nursing Process: Implementation NCLEX: Physiological Integrity

34. All of these orders are received for a patient who has vomited 1500 ml of bright red blood. Which order will the nurse act on first?
a. Infuse 1000 ml of lactated Ringer's solution.
b. Administer IV famotidine (Pepcid) 40 mg.
c. Insert NG tube and connect to suction.
d. Type and cross match for 4 units of packed red blood cells.

Answer: A
Rationale: Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions are also important to implement quickly but are not the highest priorities.

Cognitive Level: Application Text Reference: p. 996
Nursing Process: Implementation NCLEX: Physiological Integrity

35. A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about
a. the use of ranitidine (Zantac) to decrease the risk for peptic ulcers.
b. reasons for using corticosteroids to treat the arthritis.
c. substitution of acetaminophen (Tylenol) for the NSAID.
d. the benefits of misoprostol (Cytotec) in protecting the GI mucosa.

Answer: D
Rationale: Misoprostol, a prostaglandin analog, is the only drug approved in the United States for preventing gastric ulcers induced by NSAIDs. Ranitidine does increase pH but is not approved for prevention of ulcers in patients chronically taking NSAIDs. Corticosteroids increase risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.

Cognitive Level: Application Text Reference: p. 1021
Nursing Process: Planning NCLEX: Physiological Integrity

36. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take
a. sucralfate and antacids together 30 minutes before each meal.
b. antacids 30 minutes before the sucralfate.
c. sucralfate at bedtime and antacids before meals.
d. antacids after eating and sucralfate 30 minutes before eating.

Answer: D
Rationale: Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

Cognitive Level: Comprehension Text Reference: pp. 1020-1021
Nursing Process: Implementation NCLEX: Physiological Integrity

37. Which information will be best for the nurse to include when teaching a patient with PUD about dietary management of the disease?
a. "You should avoid eating many raw fruits and vegetables."
b. "High-protein foods are least likely to cause pain."
c. "Avoid foods that cause pain after you eat them."
d. "You will need to remain on a bland diet indefinitely."

Answer: C
Rationale: The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

Cognitive Level: Application Text Reference: p. 1021
Nursing Process: Implementation NCLEX: Physiological Integrity

38. A patient with acute GI bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the health care provider?
a. The NG suction is returning coffee-ground material.
b. The patient's lungs have crackles audible to the midline.
c. The patient's BP has increased to 142/94 mm Hg.
d. The bowel sounds are very hyperactive in all four quadrants.

Answer: B
Rationale: The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

Cognitive Level: Application Text Reference: p. 999
Nursing Process: Assessment NCLEX: Physiological Integrity

39. A patient who has intermittent epigastric distress, weight loss, and ascites is diagnosed with stomach cancer. The nurse plans care for the patient with the knowledge that these findings indicate that
a. the patient has a poor prognosis with any therapy.
b. surgical intervention is not indicated for the patient.
c. radiation therapy is the treatment of choice for the patient.
d. the patient will need a referral to hospice services.

Answer: A
Rationale: Survival rate for patients with stomach cancer is low and the presence of ascites indicates metastasis and is a poor prognostic sign. The patient may be a candidate for surgery, which is the only curative treatment for stomach cancer. Radiation may be used, but it is not the treatment of choice because stomach cancers do not respond well to radiation. The patient may need a referral to hospice services, but this will depend on factors such as the patient's desires and how long the patient is projected to live.

Cognitive Level: Application Text Reference: p. 1028
Nursing Process: Planning NCLEX: Physiological Integrity

40. When counseling a patient with a family history of stomach cancer about ways to decrease risk for developing stomach cancer, the nurse will teach the patient to avoid
a. chronic use of H2-blocking medications.
b. emotionally or physically stressful situations.
c. smoked foods such as bacon and ham.
d. foods that cause abdominal distension.

Answer: C
Rationale: Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distension are not associated with an increased incidence of stomach cancer.

Cognitive Level: Application Text Reference: p. 1028
Nursing Process: Implementation NCLEX: Physiological Integrity

41. The nurse will instruct the patient with GERD who is being discharged after a Stretta procedure that
a. acetaminophen (Tylenol) tablets can be used for pain.
b. postoperative nausea is an expected symptom.
c. gelatin, clear broth, and tea are appropriate foods for the next 24 hours.
d. intake and output should be measured and reported to the health care provider.

Answer: C
Rationale: The patient should remain on clear liquids for the first 24 hours after the Stretta procedure. Liquid medications, rather than tablets, are used to decrease irritation at the site. The patient is instructed to notify the health care provider if nausea or vomiting occurs. There is no need for the patient to monitor intake and output.

Cognitive Level: Application Text Reference: p. 1007
Nursing Process: Implementation NCLEX: Physiological Integrity

42. Which nursing diagnosis is appropriate for the home health nurse to use when planning care for a patient who has had a total gastrectomy with an anastomosis of the esophagus to the jejunum for treatment of stomach cancer?
a. Chronic pain related to altered GI tract function secondary to the surgery
b. Risk for infection related to ongoing need for parenteral nutrition
c. Risk for impaired skin integrity related to leakage from jejunostomy tube
d. Imbalanced nutrition: less than body requirements related to inability to absorb nutrients

Answer: D
Rationale: After this procedure, there will be less surface area for nutrient absorption and vitamins that are normally absorbed in the duodenum will have poor absorption. Chronic pain may occur, but this is due to cancer, not to changes that occur in GI function because of surgery. Parenteral nutrition may be used in the immediate postoperative period but is not needed on an ongoing basis. The patient will not have a jejunostomy tube.

Cognitive Level: Application Text Reference: p. 1031
Nursing Process: Diagnosis NCLEX: Physiological Integrity

43. The nurse suspects the possibility of Escherichia coli O157:H7 food poisoning when several individuals who have eaten in the same restaurant develop
a. fever and chills.
b. hemorrhagic diarrhea.
c. muscular incoordination.
d. nausea and vomiting.

Answer: B
Rationale: E. coli O157:H7 causes hemorrhagic colitis with bloody diarrhea. Fever and chills are not typical clinical manifestations of food poisoning. Muscular incoordination is seen with botulism. Nausea and vomiting are common with some forms of food poisoning, but not with E. coli O157:H7.

Cognitive Level: Comprehension Text Reference: p. 1031
Nursing Process: Assessment NCLEX: Physiological Integrity

44. A 22-year-old patient with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. All of the following orders are received. Which order will the nurse question?
a. Infuse lactated Ringer's solution at 250 ml/hr.
b. Monitor blood urea nitrogen and creatinine daily.
c. Administer loperamide (Imodium) after each stool.
d. Provide a clear liquid diet and progress diet as tolerated.

Answer: C
Rationale: Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate.

Cognitive Level: Application Text Reference: pp. 1031, 1033
Nursing Process: Implementation NCLEX: Physiological Integrity

FUNCTIONS OF THE DIGESTIVE TRACT

Breakdown of food for digestion
•Absorption of nutrients produced by digestion into the bloodstream
•Elimination of undigested foodstuffs and other waste products
•What is ingestion?
•Ingestion occurs when food is taken into the GI tract via mouth and esophagus. Digestion occurs when enzymes mix with ingested food and when proteins, fats, and sugars are broken down into their component molecules. Absorption occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream. Elimination occurs after digestion and absorption, when waste products are eliminated from the body.

MAJOR ENZYMES AND SECRETIONS

Mouth: saliva, salivary amylase
􀂇Stomach: hydrochloric acid, pepsin, intrinsic factor
􀂇Small intestine: amylase, lipase, trypsin, bile

AGE RELATED CHANGES IN GI TRACT

Oral Cavity/Pharynx-Difficulty chewing & swallowing
􀂇Esophagus-Reflux & Heartburn
􀂇Stomach-Food intolerance, malabsorption, or decrease in Vitamin B12 absorption
􀂇Small Intestine-Decrease motility & transit time leads to constipation & indigestion
􀂇Large Intestine-Decreased motility & transit time, leads to constipation & indigestion. Decrease absorption of nutrients. Fecal incontinence

QUADRANTS OF THE ABDOMEN

Four quadrants- right upper quadrant(RUQ)
right lower quadrant(RLQ), left upper quadrant (LUQ), Left lower quadrant (LLQ)
Nine regions-1. epigastric 2. umblical 3. hypogasgtric or suprapubic 4. right hypochondriac 5. left hypochondriac 6. right lumbar 7. left lumbar 8. right inguinal 9. left inguinal

PHYSICAL ASSESSMENT OF GI

Mouth and Throat: Assess the mouth and throat for sores, condition of teeth and gums, irritations, or any other conditions that could affect the intake of food and liquid. Lift the tongue and look under it for any tumors or lesions. Assess for any unusual breath odor.
•Abdomen: Inspect for contour, symmetry, abdominal aorta pulsation, and distention. Do not touch the abdomen during the inspection or peristalsis can be stimulated which will provide false data during the auscultation portion of the assessment. Instruct the patient to not touch the abdomen during the inspection phase.
•Abdominal distention can be caused by three factors:
•Obesity - Abdomen is soft and rounded with a sunken umbilicus.
•Ascites - Skin is shiny and glistening with an everted umbilicus. Veins are dilated and prominent (more visible in thin, malnourished skin).
•Obstruction - There may be visible, marked peristalsis; restlessness; lying with knees flexed; grimacing facial expression; and uneven respirations.
•Auscultation
•Bowel Sounds: Bowel sounds are best heard with the diaphragm portion of the stethoscope. Note the character (high-pitched, gurgling, clicking, etc.) and frequency. Normally the sounds occur intermittently at 5-15 times per minute.
•Judge if the sounds are normal, hypoactive or hyperactive. You must listen for 5 minutes to each quadrant before deciding that bowel sounds are absent (20 minutes is unrealistic to expect someone to stand and listen for bowel sounds so we often rely on the patient's other signs and symptoms). If the patient is experiencing an obstruction due to an ileus (absence of peristalsis), bowel sounds will be absent as there is no enervation by the nervous system to the area. If the patient is experiencing a mechanical obstruction (feces, volvulus, tumor, etc.), the bowel sounds can alter between being hyperactive (as the gut tries to push feces around the obstruction) or absent (as the gut rests and prepares for the next peristaltic wave; the patient will also complain of pain when bowel sounds are heard). Peritonitis presents with absent bowel sounds.
Vascular sounds: Vascular sounds are best heard with the bell of the stethoscope. Assess all four quadrants listening for bruits (whooshing, blowing sounds that represent impaired circulation within an artery or an aneurysm). An aortic pulsation may be heard over the left upper quadrant in the presence of hypertension, aortic insufficiency, or aortic aneurysm.
•Percussion
•Tympani: Tympani should predominate as air rises to surface of the abdominal cavity.
•Hyperresonance: Will be heard in the presence of gaseous distention.
•Dullness: Percussed over a distended bladder, adipose tissue, fluid, or a mass in the abdomen.
•Palpation: Prior to palpating the abdomen, have the patient bend the knees and relax the abdominal muscles. Ask the patient to point to any painful or tender areas. Save those areas to palpate last so the patient becomes more accustomed to your touch and does not guard throughout the exam. Lightly palpate the abdomen by quadrants. Note any muscle guarding, rigidity, tenderness, or masses.
•Rectal Area: Examine the external rectal area for the presence of external hemorrhoids, masses or evidence of inflammation.

DIAGNOSTIC TESTS

oStool specimens
oBreath tests
oAbdominal ultrasound
oImaging studies: CT, PET, MRI
oUpper GI tract study/Lower GI tract study
oGI motility studies
oEndoscopic procedures

LIVER BIOPSY

Purpose to obtain hepatic tissue to be used in establishing a diagnosis for fibrosis, cirrhosis, and neoplasms.
•Also used to evaluate the progression of disease. (ex. Chronic hepatitis)
•Liver function studies. (LFTs)
•ALT-Alanine Aminotransferase
•AST-Aspartate Aminotransferase

PURPOSE OF GI TUBE

Decompress the stomach
•Lavage the stomach
•Diagnose GI disorders
•Administer medications and feeding
•To treat an obstruction
•To compress a bleeding site
•To aspirate gastric contents for analysis

NURSING CARE PT W/ NASOGASTRIC, NASOENTERIC, GASTROSTOMY OR JEJUNOSTOMY TUBE

Patient teaching and preparation
•Tube insertion
•Confirming placement
•Securing the tube
•Monitoring the patient
•Maintaining tube function
•Oral and nasal care
•Monitoring, preventing, and managing complications
•Tube removal

PURPOSE & ADVANTAGES OF ENTERAL FEEDINGS

Meet nutritional requirements when oral intake is inadequate or not possible, and the GI tract is functioning.
•Advantages:
▫Safe and cost-effective
▫Preserve GI integrity
▫Preserve the normal sequence of intestinal and hepatic metabolism
▫Maintain fat metabolism and lipoprotein synthesis
▫Maintain normal insulin and glucagon ratios

NURSING MGT. DECREASE RISK OF FEEDING MISCONNECTIONS

Teach visitors & nursing assistants to notify RN if enteral feeding becomes disconnected that only the RN is to reconnect the feeding line
• Do NOT modify or adapt IV or feeding devices because you can compromise the safety features in the design
•When patient arrives or shift report the RN checks all connections and traces back to all tubes
•Label feeding tube lines and connectors if needed
•Always read the label confirming what it is and label if needed for Enteral use only NOT IV use

FEEDING TUBE MISCONNECTION EXAMPLES

Examples of tubing misconnections that may lead to severe illness or death include:
•Liquid feedings or formula intended for a feeding tube or nasogastric (NG) tube into the stomach is accidentally connected to an intravenous (IV) line -delivers liquid feeding into the bloodstream.
•A non-invasive blood pressure insufflation tube is accidentally connected to IV line--delivers air under pressure into the bloodstream causing an air embolism.
•IV fluids are accidentally connected to the inflation cuff on a breathing tube (tracheostomy or endotracheal tube) --delivers a large volume of fluid to a fixed volume device designed to be filled with air (the cuff), causing it to burst with fluid leaking into the airway resulting in airway obstruction.
•NG or tube feedings accidentally connected to a peritoneal dialysis catheter—delivers formula intended for the stomach to the abdominal (peritoneal) cavity.

COMPLICATIONS OF NASOGASTRIC TUBE FEEDINGS

obstruction of the tube
•perforation of the tube
•tube migration out of correct position
•regurgitation and aspiration of the feeding
•diarrhea
•nausea and vomiting
•abdominal distention, cramping and discomfort from too much feeding or a rate of feeding that is too rapid
•constipation and dehydration

MAINTAINING NUTRITION BALANCE & TUBE FUNCTION

Administer feeding at prescribed rate and method and according to patient tolerance.
•Measure residual prior to intermittent feedings and every 4-8 hours during continuous feedings.
•Administer water before and after each medication and each feeding, before and after checking residual, every 4-6 hours, and whenever the tube feeding is discontinued or interrupted.
•Do not mix medications with feedings.
•Use a 30-mL or larger syringe.
•Maintain delivery system as required. To avoid bacterial contamination, do not hang more than 4 hours of feeding in an open system.

CARE OF PT RECV ENTERAL FEEDING-ASSESSMENT

Nutritional status and nutritional assessment
•Factors or illnesses that increase metabolic needs
•Hydration and fluid needs
•Digestive tract function
•Renal function and electrolyte status
•Medications and other theories that effect nutrition intake and function of the GI tract
•Compare the dietary prescription to the patient needs.

CARE OF PT RECV ENTERAL FEEDING-PLANNING

Major goals may include nutritional balance, normal bowel elimination pattern, reduced risk of aspiration, adequate hydration, individual coping, knowledge and skill in self-care, and prevention of complications.

MAINTAINING NORMAL BOWEL ELIMINATION

Selection of TF formula; consider fiber, osmolality, and fluid content
•Prevent contamination of TF; maintain closed system, do not hang more than 4 hours TF in an open system
•Maintain proper nutritional intake
•Assess for reason for diarrhea and obtain treatment as needed
•Administer TF slowly to prevent dumping syndrome
•Avoid cold TF

PREPARING MED FOR DELIVERY BY FEEDING TUBE

Liquid- no Prep
•Simple tablets-crush and dissolve in water
•Buccal & Sublingual tablets-administer as ordered
•Soft gelatin capsules-make opening & squeeze out liquid
•Enteric coated tablets-Do not crush (will need a different form)
•Time-released tablets-Do not crush tablets (may release too soon)
•Timed-release capsules-Some can be opened & contest added to tube feeding formula check with pharmacist first

REDUCE RISK FOR ASPIRATION

Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings
•Monitor residual volumes

CARE OF PT W/ GASTROSTOMY-ASSESSMENT

Patient knowledge and ability to learn
•Self-care ability and support
•Skin condition
•Nutrition and fluid status

CARE OF PT W/ GASTROSTOMY-DIAGNOSES

Imbalanced nutrition
•Risk of infection
•Risk for impaired skin integrity
•Ineffective coping
•Disturbed body image
•Risk for ineffective therapeutic regimen management

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

Wound infection
•GI bleeding
•Premature removal of tube
•Aspiration
•Constipation
•Diarrhea

TUBE CARE & PREVENTING INFECTION

Proper use of dressing
•Skin care around the tube
•Manipulation of the stabilizing disk to prevent sin breakdown

CONSTIPATION

Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem.
•Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise.
•Increased risk in older age.
•Perceived constipation: a subjective problem in which the person's elimination pattern is not consistent with what he or she believes is normal.

MANIFESTATIONS

Fewer than 3 BMs per week
•Abdominal distention
•Decreased appetite
•Headache
•Fatigue
•Indigestion
•A sensation of incomplete evacuation
•Straining at stool
•Elimination of small-volume, hard, dry stools

COMPLICATIONS

Hypertension
•Fecal impaction
•Hemorrhoids
•Fissures
•Megacolon

PT LEARNING NEEDS

See Chart 38-1
•Normal variations of bowel patterns
•Establishment of normal pattern
•Dietary fiber and fluid intake
•Responding to the urge to defecate
•Exercise and activity
•Laxative use (see Table 38-1)

DIARRHEA

Increased frequency of bowel movements (more than 3 per day), increase amount of stool (more than 200 g per day), and altered consistency (i.e., looseness) of stool.
•Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors.
•May be acute or chronic.
•Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes.

MANIFESTATIONS OF DIARRHEA

Increased frequency and fluid content of stools
•Abdominal cramps
•Distention
•Borborygmus-Intestinal rumbling
•Painful spasmodic contractions of the anus
•Tenesmus-ineffective straining

COMPLICATIONS/MED MANAGEMENT OF DIARRHEA

Fluid and electrolyte imbalances
•Dehydration
•Cardiac dysrhythmias
•********************************************
•Antibiotics
•Antidiarrheals (Lomotil, Imodium)

PT LEARNING NEEDS FOR DIARRHEA

Recognition of need for medical treatment
•Rest
•Diet and fluid intake
•Avoid irritating foods—caffeine, carbonated beverages, very hot and cold foods
•Perianal skin care
•Medications
•May need to avoid milk, fat, whole grains, fresh fruit, and vegetables
•Lactose intolerance (see Chart 38-2)

CONDITIONS OF MALABSORPTION

The inability of the digestive system to absorb one or more of the major vitamins, minerals, and nutrients
•Conditions (see Table 38-2)
▫Mucosal (transport) disorders
▫Infectious disease
▫Luminal disorders
▫Postoperative malabsorption
▫Disorders that cause malabsorption of specific nutrients

APPENDICITIS

A small finger like appendage about 4 inches long that is attached to the cecum just below the ileocecal valve. The appendix fills with food & empties inefficiently and its lumen is small, and it is prone to obstruction and infection.
•Most common cause of acute surgical abd of the U.S. & most common reason for emergency abd surgery
•Complications is perforation of the appendix which can lead to peritonitis, abcess formation
•Immediate surgery is typical for appendicitis

DIVERTICULAR DISEASE

Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer
•May occur anywhere in the intestine but are most common in the sigmoid colon
•Diverticulosis: multiple diverticula without inflammation
•Diverticulitis: infection and inflammation of diverticula
•Diverticular disease increases with age and is associated with a low-fiber diet
•Diagnosis is usually by colonoscopy

CARE OF PT W/ DIVERTICULITIS-ASSESSMENT

Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention.
•With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis.
•Ask regarding the onset and duration of pain, and past and present elimination patterns.
•Nutrition and dietary patterns including fiber intake.
•Inspect stool and monitor for symptoms potential complications.

CARE OF PT W/ DIVERTICULITIS-DIAGNOSES

Constipation
Acute pain
Collaborative Problems/Potential Complications
Perforation
Peritonitis
Abscess formation
Bleeding

CARE OF PT W/ DIVERTICULITIS-PLANNING

Major goals may include attainment and maintenance of normal elimination patterns, pain, relief, and absence of complications.

MAINTAINING NORMAL ELIMINATION PATTERN

Encourage fluid intake of at least 2 L/d
•Soft foods with increased fiber, such as cooked vegetables
•Individualized exercise program
•Bulk laxatives (psyllium) and stool softeners

IRRITABLE BOWEL SYNDROME

Is one of the most common GI conditions
•Treatment is directed at psychologic & dietary factors as well as medications to regulate stool output.
•Gender Differences
• Men-More men report manifestations of diarrhea and less likely to admit to symptoms or seek help for them than women
•Women-More women report manifestations of constipation and report more extra co-morbidities
•Lotronex (antidiarrheal) is approved for women with severe IBS diarrhea

PERITONITIS

Results from a localized or generalized inflammatory processes of the peritoneum
•Occurs when abdominal organs perforated or rupture and release their contents (bile, enzymes, & bacteria) into the peritoneal cavity
•Common cause: ruptured appendix, perforated gastric or duodenal ulcer, severely inflamed gallbladder, and trauma from a gunshot or knife wounds.

NURSING IMPLEMENTATION FOR PERITONISTIS

IV line inserted to replace vascular fluids lost to the peritoneal cavity as access for antibiotic therapy
•Position the knees flexed to increase comfort.
•Sedative given to decrease anxiety
•Accurate Intake and Output and electrolyte status is necessary
•Antiemetics may be given to decrease nausea and vomiting to prevent further fluid & electrolyte losses.
•NPO status and may need and NGT to decrease gastric distention
•Oxygen may be needed

INFLAMMATORY BOWEL DISEASE

Classified as two different disorders:
•Crohn's disease (regional enteritis)
•Ulcerative colitis
•See Table 38-4

CROHN'S DISEASE

CHARACTERISTICS
•Age to start- teens to mid 30s
•Diarrhea- common
•Abdominal Cramping pain- common
•Fever (intermittent)- common
•Weight loss- Common & may be severe
•Rectal bleeding- Infrequent
•Tenesumus- Rare
•Malabsorption & nutritional deficiencies- Common

CROHN'S DISEASE PATHOLOGY

Location- occurs anywhere in the GI tract in characterisitic skip, terminal ileum main site
•Distribution- Healthy tissue is intersperses with areas of inflammation (skip lesions)
•Depth of involvement- Entire thickness of bowel wall
•Granulomas (on biopsy)- Common
•Cobblestoning of mucosa- Common
•Pseudopolyps- Rare
•Small bowel involvement- Common

CROHN'S DISEASE COMPLICATIONS

Fistulas- common
•Strictures- common
•Anal Abscesses- common
•Perforation- common (inflammation involves entire bowel wall)
•Toxic Megacolon- Rare
•Carcinoma- Small intestine, increased; colon increased but not as much as with ulcerative colitis
•Recurrence after surgery- common at site of anastomosis

ULCERATIVE COLITIS CHARACTERISTICS

Usual age at onset- Teens to mid 30s
•Diarrhea- common
•Abdominal cramping pain- common
•Fever (intermittent)- during acute attacks
•Weight loss- rare
•Rectal bleeding- common
•Tenesmus- common
•Malabsorption and nutritional deficiencies- Minimal incidence

ULCERATIVE COLITIS PATHOLOGY

Location- usually starts in rectum & spreads in a continuous pattern up the colon
•Distribution- Continuous areas of inflammation
•Depth of involvement- Mucosa & submucosa
•Granulomas (noted on biopsy)- Occasional
•Cobblestoning of mucosa- Rare
•Pseudopolyps- Common
•Small bowel involvement- Minimal

ULCERATIVE COLITIS COMPLICATIONS

Fistulas- Rare
•Strictures- Occasional
•Anal Abscesses- Rare
•Perforation- common (because of toxic megacolon)
•Toxic Megacolon- Relatively more common
•Carcinoma- increased incidence after 10 year of disease
•Recurrence after surgery- Cure with colectomy

ULCERATIVE COLITIS COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Electrolyte imbalance
•Cardiac dysrhythmias
•GI bleeding with fluid loss
•Perforation of the bowel

CARE OF PT W/ INFLAMMATORY BOWEL DISEASE-ASSESSMENT

Health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history
•Discuss dietary patterns, alcohol, caffeine, and nicotine use
•Assess bowel elimination patterns and stool
•Abdominal assessment

CARE OF PT W/ INFLAMMATORY BOWEL DISEASE-DIAGNOSES

Diarrhea
•Acute pain
•Deficient fluid
•Imbalanced nutrition
•Activity intolerance
•Anxiety
•Ineffective coping
•Risk for impaired skin integrity
•Risk for ineffective therapeutic regimen management

CARE OF PT W/ INFLAMMATORY BOWEL DISEASE-PLANNING

Major goals may include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge of disease process and therapeutic regimen, and avoidance of complications.

SURGICAL MANAGEMENT OF CHRONIC INFLAMMATORY BOWEL DISEASE

When nonsurgical measures fail to relieve the severe symptoms of IBD, surgery may be necessary.
•Usually 75% of patients with Crohn's disease undergo surgery within 10 yrs of diagnosis.
•The most common indications for surgery are medically intractable disease, poor quality of life, or complications from the disease or its treatment
•Surgical removal of up to 50% of the small bowel usually can be tolerated

NORMAL ELIMINATION PATTERN W/ IBD

Identify relationship between diarrhea and food, activities, or emotional stressors.
•Provide ready access to bathroom/commode.
•Encourage bed rest to reduce peristalsis.
•Administer medications as prescribed.
•Record frequency, consistency, character, and amounts of stools.

PT W/ AN INTESTINAL DIVERSION

Preoperative care
•Postoperative care
•Emotional support
•Skin and stoma care
•Irrigation of a Kock's pouch (continent ileostomy). Diet and fluid intake
•Prevention of complications

OTHER INTERVENTIONS FOR IBD

Assessment and treatment of pain/discomfort, anticholinergic medications prior to meals, analgesics, positioning, diversional activities, and prevention of fatigue
•Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration/fluid loss, encourage oral intake, measures to decrease diarrhea
•Optimal nutrition; elemental feedings that are high in protein and low residue or Parenteral Nutrition may be needed
•Reduce anxiety; calm manner, allow patient to express feelings, listening, patient teaching

PT TEACHING

Understanding of disease process
•Nutrition/diet
•Medications
•Information sources: National Foundation for Ileitis and Colitis
•Ileostomy care if applicable

1. A health care provider who has not been immunized for hepatitis B is exposed to the hepatitis B virus (HBV) through a needle stick from an infected patient. The infection control nurse informs the individual that treatment for the exposure should include
a. baseline hepatitis B antibody testing now and in 2 months.
b. active immunization with hepatitis B vaccine.
c. hepatitis B immune globulin (HBIG) injection.
d. both the hepatitis B vaccine and HBIG injection.

D
Rationale: The recommended treatment for exposure to hepatitis B in unvaccinated individuals is to receive both HBIG and the hepatitis B vaccine, which would provide temporary passive immunity and promote active immunity. Antibody testing may also be done, but this would not provide protection from the exposure.

Cognitive Level: Application Text Reference: p. 1096
Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, the nurse would expect serologic testing to reveal
a. hepatitis B surface antigen (HBsAg).
b. anti-hepatitis B core immunoglobulin M (anti-HBc IgM).
c. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
d. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

D
Rationale: Hepatitis A is transmitted through the oral-fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen or antibodies for hepatitis B. Anti-HAV IgG would indicate past infection and lifelong immunity.

Cognitive Level: Application Text Reference: p. 1089
Nursing Process: Assessment NCLEX: Physiological Integrity

3. During evaluation of a patient at an outpatient clinic, the nurse determines that administration of hepatitis B vaccine has been effective when a specimen of the patient's blood reveals
a. HBsAg.

b. anti-HBs.
c. anti-HBc IgM.
d. anti-HBc IgG

B
Rationale: The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

Cognitive Level: Application Text Reference: pp. 1089, 1093
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

4. A patient in the outpatient clinic has positive serologic testing for anti-HCV. Which action by the nurse is appropriate?
a. Schedule the patient for HCV genotype testing.
b. Teach the patient that the HCV will resolve in 2 to 4 months.
c. Administer immune globulin and the HCV vaccine.
d. Instruct the patient on self-administration of -interferon.

A
Rationale: Genotyping of HCV has an important role in managing treatment and is done before drug therapy with -interferon or other medications is started. HCV has a high percentage of conversion to the chronic state so the nurse should not teach the patient that the HCV will resolve in 2 to 4 months. Immune globulin or vaccine is not available for HCV.

Cognitive Level: Application Text Reference: p. 1092
Nursing Process: Planning NCLEX: Physiological Integrity

5. A homeless patient with severe anorexia, fatigue, jaundice, and hepatomegaly is diagnosed with viral hepatitis and has just been admitted to the hospital. In planning care for the patient, the nurse assigns the highest priority to the patient outcome of
a. maintaining adequate nutrition.
b. establishing a stable home environment.
c. increasing activity level.
d. identifying the source of exposure to hepatitis.

A
Rationale: The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as having adequate nutrition. Although the patient's activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

Cognitive Level: Application Text Reference: p. 1097
Nursing Process: Planning NCLEX: Physiological Integrity

6. A patient with acute hepatitis B asks the nurse if treatment is available for the condition. The nurse explains to the patient that
a. because no medication is available to treat acute viral hepatitis, adequate nutrition and rest are the most important treatments.
b. lamivudine (Epivir) can decrease viral load and liver damage in patients with acute hepatitis B, but it must be taken for at least 1 year.
c. patients with acute hepatitis B can be given HBIG to help reduce the symptoms.
d. various antiviral drugs are available to treat acute hepatitis B, but serious side effects limit their use.

A
Rationale: There are no drug therapies to treat acute hepatitis, although -interferon and nucleoside analogs (i.e., lamivudine) may be used to treat chronic hepatitis B. Immune globulin may be given within 24 hours after exposure to prevent hepatitis B, but it is not used to decrease symptoms for patients with acute hepatitis.

Cognitive Level: Application Text Reference: p. 1093
Nursing Process: Implementation NCLEX: Physiological Integrity

7. Combination therapy of -interferon and ribavirin (Rebetol) is being used to treat hepatitis C in a patient with human immunodeficiency virus (HIV). The nurse will plan to monitor
a. blood glucose.
b. lymphocyte count.
c. potassium level.
d. serum creatinine.

B
Rationale: Therapy with ribavirin and -interferon may decrease lymphocyte counts. The other laboratory values should not be changed by the drug therapy.

Cognitive Level: Application Text Reference: p. 1095
Nursing Process: Planning NCLEX: Physiological Integrity

8. When taking a health history for a new patient, which information given by the patient would indicate that screening for hepatitis C is appropriate?
a. The patient had a blood transfusion after surgery in 1998.
b. The patient reports a one-time use of IV drugs 20 years ago.
c. The patient eats frequent meals in fast-food restaurants.
d. The patient recently traveled to an undeveloped country.

B
Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

Cognitive Level: Application Text Reference: pp. 1090, 1098
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

9. A patient is admitted with an abrupt onset of jaundice, nausea and vomiting, hepatomegaly, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?
a. "Have you been around anyone with jaundice?"
b. "Do you use any prescription or over-the-counter (OTC) drugs?"
c. "Are you taking corticosteroids for any reason?"
d. "Is there any history of IV drug use?"

B
Rationale: The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Exposure to a jaundiced individual and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

Cognitive Level: Application Text Reference: pp. 1099-1100
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

10. When teaching a patient recovering from hepatitis B about management of the illness, the nurse determines that additional teaching is needed when the patient says
a. "I should not drink alcohol for at least the next year."
b. "My family members should be tested for hepatitis B."
c. "When the jaundice is gone, I have recovered from my illness and the infection is cured."
d. "Until my tests for the virus are negative, I should use a condom for sexual intercourse."

C
Rationale: After the acute (icteric) phase, there is a convalescent phase lasting several months. The other patient statements are correct and indicate that teaching has been effective.

Cognitive Level: Application Text Reference: pp. 1091, 1098
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance

11. A patient with cirrhosis has 4+ pitting edema of the feet and legs and massive ascites. The data indicate that it is most important for the nurse to monitor the patient's
a. temperature.
b. albumin level.
c. hemoglobin.
d. activity level.

B
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of ascites and edema. The other parameters should also be monitored, but they are not contributing factors to the patient's current symptoms.

Cognitive Level: Application Text Reference: p. 1104
Nursing Process: Assessment NCLEX: Physiological Integrity

12. A 32-year-old patient has early alcoholic cirrhosis diagnosed by a liver biopsy. When planning patient teaching, the priority information for the nurse to include is the need for
a. vitamin B supplements.
b. abstinence from alcohol.
c. maintenance of a nutritious diet.
d. long-term, low-dose corticosteroids.

B
Rationale: The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

Cognitive Level: Application Text Reference: pp. 1114-1115
Nursing Process: Planning NCLEX: Physiological Integrity

13. A patient with cirrhosis who is being treated with spironolactone (Aldactone) and furosemide (Lasix) has a serum sodium level of 135 mEq/L (135 mmol/L) and serum potassium 3.2 mEq/L (3.2 mmol/L). Before notifying the health care provider, the nurse should
a. administer the furosemide and withhold the spironolactone.
b. give both drugs as scheduled.
c. administer the spironolactone.
d. withhold both drugs until talking with the health care provider.

C
Rationale: Spironolactone is a potassium-sparing diuretic and will help to increase the patient's potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient's potassium level and should be held until the nurse talks with the health care provider.

Cognitive Level: Application Text Reference: p. 1107
Nursing Process: Implementation NCLEX: Physiological Integrity

14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to
a. stand on one foot.
b. ambulate with the eyes closed.
c. extend both arms.
d. perform the Valsalva maneuver.

C
Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

Cognitive Level: Comprehension Text Reference: p. 1106
Nursing Process: Assessment NCLEX: Physiological Integrity

15. When lactulose (Cephulac) 30 ml QID is ordered for a patient with advanced cirrhosis, the patient complains that it causes diarrhea. The nurse explains to the patient that it is still important to take the drug because the lactulose will
a. promote fluid loss.
b. prevent constipation.
c. prevent gastrointestinal (GI) bleeding.
d. improve nervous system function.

D
Rationale: The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although the medication may promote fluid loss through the stool, prevent constipation, and prevent bearing down during bowel movements (which could lead to esophageal bleeding), the medication is not ordered for these purposes for this patient.

Cognitive Level: Application Text Reference: p. 1109
Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient who is admitted with acute hepatic encephalopathy and ascites receives instructions about appropriate diet. The nurse determines that the teaching has been effective when the patient's choice of foods from the menu includes
a. an omelet with cheese and mushrooms and milk.
b. pancakes with butter and honey and orange juice.
c. baked beans with ham, cornbread, potatoes, and coffee.
d. baked chicken with french-fries, low-fiber bread, and tea.

B
Rationale: The patient with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia levels. The other choices are all higher in protein and would not be as appropriate for this patient. In addition, the patient's ascites indicate that a low-sodium diet is needed and the other choices are all high in sodium.

Cognitive Level: Application Text Reference: p. 1110
Nursing Process: Evaluation NCLEX: Physiological Integrity

17. A patient with cirrhosis has a massive hemorrhage from esophageal varices. In planning care for the patient, the nurse gives the highest priority to the goal of
a. controlling bleeding.
b. maintenance of the airway.
c. maintenance of fluid volume.
d. relieving the patient's anxiety.

B
Rationale: Maintaining gas exchange has the highest priority because oxygenation is essential for life. The airway is compromised by the bleeding in the esophagus and aspiration easily occurs. The other goals would also be important for this patient, but they are not as high a priority as airway maintenance.

Cognitive Level: Application Text Reference: pp. 1107, 1114
Nursing Process: Planning NCLEX: Physiological Integrity

18. During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care?
a. Encourage the patient to cough and deep breathe.
b. Insert the tube and verify its position q4hr.
c. Monitor the patient for shortness of breath.
d. Deflate the gastric balloon q8-12hr.

C
Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

Cognitive Level: Application Text Reference: p. 1114
Nursing Process: Implementation NCLEX: Physiological Integrity

19. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor
a. prothrombin time.
b. bilirubin levels.
c. ammonia levels.
d. potassium levels.

C
Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode.

Cognitive Level: Application Text Reference: p. 1113
Nursing Process: Assessment NCLEX: Physiological Integrity

20. The nurse identifies a nursing diagnosis of risk for impaired skin integrity for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet and legs. An appropriate nursing intervention for this problem is to
a. restrict dietary protein intake.
b. arrange for a pressure-relieving mattress.
c. perform passive range of motion QID.
d. turn the patient every 4 hours.

B
Rationale: The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Dietary protein intake may be increased in patients with ascites to improve oncotic pressure. Turning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.

Cognitive Level: Application Text Reference: p. 1111
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

21. A portocaval shunt is considered for a patient with cirrhosis following an episode of bleeding esophageal varices. The nurse plans to teach the patient that this procedure
a. is likely to improve the patient's life expectancy.
b. will increase the risk of hepatic encephalopathy.
c. will help to decrease the incidence of peritonitis.
d. is a first-line therapy for portal hypertension.

B
Rationale: The risk for hepatic encephalopathy increases after shunt procedures because blood bypasses the portal system and ammonia is diverted past the liver and into the systemic circulation. Life expectancy is not improved. The risk for peritonitis is not decreased by a surgical procedure, which will increase infection risk. First-line procedures for portal hypertension are medications such as diuretics and albumin.

Cognitive Level: Application Text Reference: p. 1108
Nursing Process: Planning NCLEX: Physiological Integrity

22. A patient with cancer of the liver has severe ascites, and the health care provider plans a paracentesis to relieve the fluid pressure on the diaphragm. To prepare the patient for the procedure, the nurse
a. asks the patient to empty the bladder.
b. positions the patient on the right side.
c. obtains informed consent for the procedure.
d. assists the patient to lie flat in bed.

A
Rationale: The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. The health care provider is responsible for obtaining informed consent.

Cognitive Level: Application Text Reference: p. 1111
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment

23. A patient with end-stage liver disease who is to undergo a liver transplant tells the nurse, "I have a friend who has already rejected two kidney transplants. I am concerned that I will reject this liver." The nurse's best response to the patient is
a. "Perhaps your friend did not have a good tissue match with the kidney transplants."
b. "You would not be scheduled for a transplant if there was a concern about rejection."
c. "The problem of rejection is not as common in liver transplants as in kidney transplants."
d. "It is easier to get a good tissue match with liver transplants than with kidney transplants."

C
Rationale: The liver is less susceptible to rejection than the kidney. The other statements are inaccurate or will not decrease the patient's anxiety.

Cognitive Level: Application Text Reference: p. 1118
Nursing Process: Implementation NCLEX: Physiological Integrity

24. A patient hospitalized with possible acute pancreatitis has severe abdominal pain and nausea and vomiting. The nurse would expect the diagnosis to be confirmed with laboratory testing that reveals elevated serum
a. calcium.
b. bilirubin.
c. amylase.
d. potassium.

C
Rationale: Amylase is elevated early in acute pancreatitis. Changes in bilirubin, calcium, and potassium levels are not diagnostic for pancreatitis.

Cognitive Level: Comprehension Text Reference: pp. 1120-1121
Nursing Process: Assessment NCLEX: Physiological Integrity

25. In planning care for a patient with acute pancreatitis, the nurse assigns the highest priority to the patient outcome of
a. developing no acute complications.
b. maintenance of normal respiratory function.
c. expressing satisfaction with pain control.
d. having adequate fluid and electrolyte balance.

B
Rationale: Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes would also be appropriate for the patient.

Cognitive Level: Application Text Reference: p. 1122
Nursing Process: Planning NCLEX: Physiological Integrity

26. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. The nurse explains to the patient that the major purpose of this treatment is
a. control of fluid and electrolyte imbalance.
b. relief from nausea and vomiting.
c. reduction of pancreatic enzymes.
d. removal of the precipitating irritants.

C
Rationale: Pancreatic enzymes are released when the patient eats. NG suction and NPO status decrease the release of these enzymes. Fluid and electrolyte imbalances will be caused by NG suction and require that the patient receive IV fluids to prevent this. The patient's nausea and vomiting may decrease, but this is not the major reason for these treatments. The pancreatic enzymes that precipitate the pancreatitis are not removed by NG suction.

Cognitive Level: Application Text Reference: p. 1120
Nursing Process: Implementation NCLEX: Physiological Integrity

27. The nurse identifies the collaborative problem of potential complication: electrolyte imbalance for a patient with severe acute pancreatitis. Assessment findings that alert the nurse to electrolyte imbalances associated with acute pancreatitis include
a. muscle twitching and finger numbness.
b. paralytic ileus and abdominal distention.
c. hypotension.
d. hyperglycemia.

A
Rationale: Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

Cognitive Level: Analysis Text Reference: p. 1122
Nursing Process: Assessment NCLEX: Physiological Integrity

28. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of
a. cigarette smoking.
b. alcohol use.
c. diabetes mellitus.
d. high-protein diet.

B
Rationale: Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

Cognitive Level: Comprehension Text Reference: p. 1118
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance

29. The health care provider prescribes pancreatin (Viokase) for a patient with chronic pancreatitis. The nurse teaches the patient that the drug is considered effective if the patient experiences
a. normal-appearing stools.
b. decreased jaundice.
c. improved appetite.
d. reduced abdominal pain.

A
Rationale: The patient's steatorrhea should improve if the pancreatic enzymes are effective. The pancreatin will not decrease jaundice, improve appetite, or reduce abdominal pain.

Cognitive Level: Application Text Reference: p. 1125
Nursing Process: Evaluation NCLEX: Physiological Integrity

30. When the nurse is caring for the patient with pancreatic cancer, which nursing diagnosis is a priority?
a. Chronic pain related to tumor pressure on abdominal structures
b. Imbalanced nutrition: less than required related to anorexia
c. Impaired skin integrity related to itching secondary to jaundice
d. Grieving related to potentially terminal diagnosis

A
Rationale: All of these nursing diagnoses are appropriate for a patient with pancreatic cancer, but treating the patient's pain is the priority because the patient will be unable to meet outcomes for the other nursing diagnoses unless the pain is controlled.

Cognitive Level: Application Text Reference: pp. 1122, 1126
Nursing Process: Diagnosis NCLEX: Physiological Integrity

31. A patient who is admitted to the hospital with a sudden onset of severe right upper-quadrant pain that radiates to the right shoulder is diagnosed with cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider?
a. The patient has an increase in pain after eating.
b. The patient needs 4 mg of morphine for pain relief.
c. The patient's stools are clay colored.
d. The patient's urine is bright yellow.

C
Rationale: The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse would also report the other assessment information to the health care provider.

Cognitive Level: Application Text Reference: p. 1128
Nursing Process: Assessment NCLEX: Physiological Integrity

32. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to
a. turn, cough, and deep breathe every 2 hours.
b. choose low-fat foods from the menu.
c. perform leg exercises hourly while awake.
d. ambulate the evening of the operative day.

A
Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

Cognitive Level: Application Text Reference: p. 1131
Nursing Process: Planning NCLEX: Physiological Integrity

33. An appropriate collaborative problem for the nurse to include in the care plan for a patient with cholelithiasis and obstruction of the common bile duct is
a. potential complication: bleeding.
b. potential complication: gastritis.
c. potential complication: thromboembolism.
d. potential complication: biliary cirrhosis.

D
Rationale: With obstruction of the common bile duct, bile will back up into the liver and damage liver cells. Bleeding, gastritis, and thromboembolism are not common complications of biliary obstruction.

Cognitive Level: Comprehension Text Reference: pp. 1128-1129
Nursing Process: Planning NCLEX: Physiological Integrity

34. When providing discharge instructions to a patient following a laparoscopic cholecystectomy at an outpatient surgical center, the nurse recognizes that teaching has been effective when the patient states,
a. "I should plan to limit my activities and not return to work for 4 to 6 weeks."
b. "I can expect some reddish yellow drainage from the incisions for a few days."
c. "I can remove the bandages on my incisions tomorrow and take a shower."
d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

C
Rationale: After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions; patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

Cognitive Level: Application Text Reference: p. 1132
Nursing Process: Evaluation NCLEX: Physiological Integrity

35. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?
a. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
b. The patient has ascites and a 2-kg weight gain from the previous day.
c. The patient complains of right upper-quadrant pain with abdominal palpation.
d. The patient's hands flap back and forth when the arms are extended.

D
Rationale: The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper-quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status.

Cognitive Level: Application Text Reference: p. 1106
Nursing Process: Assessment NCLEX: Physiological Integrity

36. A patient with severe cirrhosis has a new prescription for propranolol (Inderal). The nurse will teach the patient that the medication is ordered to
a. decrease systemic BP.
b. prevent the development of ischemia.
c. lower the risk for bleeding varices.
d. reduce fluid retention and edema.

C
Rationale: -blockers have been shown to decrease the risk for bleeding in esophageal varices. Although propranolol will decrease BP and prevent cardiac ischemia, these are not the purposes for this patient. Propranolol will not decrease fluid retention or edema.

Cognitive Level: Application Text Reference: p. 1107
Nursing Process: Implementation NCLEX: Physiological Integrity

37. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate?
a. The medication will inhibit the development of gastric ulcers.
b. The medication will prevent irritation to the esophageal varices.
c. The medication will decrease nausea and anorexia.
d. The medication will reduce the risk for aspiration.

B
Rationale: The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient.

Cognitive Level: Application Text Reference: p. 1108
Nursing Process: Implementation NCLEX: Physiological Integrity

38. Which of these nursing actions included in the plan of care for a patient with cirrhosis can the nurse delegate to a nursing assistant?
a. Assessing the patient for jaundice
b. Assisting the patient in choosing the diet
c. Palpating the abdomen for distention
d. Providing oral hygiene before meals

D
Rationale: Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs.

Cognitive Level: Application Text Reference: pp. 1110-1115
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

39. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient's hand. Which action should the nurse take next?
a. Notify the health care provider immediately.
b. Retake the patient's blood pressure.
c. Check the calcium level on the chart.
d. Ask the patient about any arm pain.

C
Rationale: The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse learns the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

Cognitive Level: Analysis Text Reference: p. 1122
Nursing Process: Assessment NCLEX: Physiological Integrity

40. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse is the best indicator that these therapies have been effective?
a. Bowel sounds are present.
b. Abdominal pain is decreased.
c. Electrolyte levels are normal.
d. Grey Turner sign resolves.

B
Rationale: NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective.

Cognitive Level: Application Text Reference: p. 1120
Nursing Process: Evaluation NCLEX: Physiological Integrity

41. When the nurse is caring for a patient with acute pancreatitis, which of these assessment data should be of most concern?
a. Absent bowel sounds
b. Abdominal tenderness
c. Left upper quadrant pain
d. Palpable abdominal mass

D
Rationale: A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

Cognitive Level: Application Text Reference: p. 1119
Nursing Process: Assessment NCLEX: Physiological Integrity

1. A patient with acute diarrhea of 24 hours' duration calls the clinic to ask for directions for care. In talking with the patient, the nurse should
a. ask the patient to describe the character of the stools and any associated symptoms.
b. advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility.
c. inform the patient that laboratory testing of blood and stool specimens will be necessary.
d. advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.

Answer: A
Rationale: The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.

Cognitive Level: Application Text Reference: p. 1037
Nursing Process: Assessment NCLEX: Physiological Integrity

2. A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will
a. order a diet with no dairy products for the patient.
b. place the patient in a private room with contact isolation.
c. explain to the patient why antibiotics are not being used.
d. teach the patient about proper food handling and storage.

Answer: B
Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

Cognitive Level: Application Text Reference: p. 1038
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment

3. A patient who is hospitalized with a diagnosis of Giardia lamblia infection frequently has uncontrollable explosive diarrhea. The patient closes the eyes and will not talk to the nurse when the linens are changed and skin care is performed. To help maintain the patient's self-esteem, the nurse should
a. use incontinence briefs for the patient so that the cleaning is less cumbersome and embarrassing.
b. request an order for an antidiarrheal drug from the health care provider to help control the diarrhea episodes.
c. ensure the patient that the lack of control is temporary and will resolve after about a week of treatment.
d. acknowledge the behavior as reflective of a difficult situation and provide privacy during hygiene.

Answer: D
Rationale: Acknowledging the difficulty of the situation and providing privacy will decrease the patient's embarrassment about the incontinence. Incontinence briefs are usually perceived as humiliating for patients. Use of antidiarrheal medications prolongs the exposure to the Giardia by slowing GI motility. Giardia may take several months to resolve.

Cognitive Level: Application Text Reference: pp. 1039-1040
Nursing Process: Implementation NCLEX: Psychosocial Integrity

4. A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." The most appropriate nursing action at this time is to
a. encourage the patient to drink at least 3000 ml of fluid a day.
b. inform the patient that a daily bowel movement is not necessary.
c. perform a focused nursing assessment to identify risk factors for constipation.
d. suggest that the patient increase dietary intake of foods that are high in fiber.

Answer: C
Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

Cognitive Level: Application Text Reference: pp. 1042-1043
Nursing Process: Implementation NCLEX: Physiological Integrity

5. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about the use of the drug, the nurse stresses that
a. the use of this type of laxative is safe and adverse effects are very minimal.
b. large amounts of fluid should be taken to prevent impaction or bowel obstruction.
c. dietary sources of fiber should be eliminated to prevent excessive gas formation.
d. fat-soluble vitamins must be taken because the drug blocks absorption of these vitamins.

Answer: B
Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives.

Cognitive Level: Comprehension Text Reference: pp. 1042, 1044
Nursing Process: Implementation NCLEX: Physiological Integrity

6. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 82/50. Of the following collaborative interventions, which one should the nurse implement first?
a. Infuse 1000 ml of lactated Ringer's solution over 30 minutes.
b. Administer IV ketorolac (Toradol) 15 mg.
c. Give IV ceftriaxone (Rocephin) 1 g.
d. Obtain a computed tomography (CT) scan of the abdomen with and without contrast.

Answer: A
Rationale: The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

Cognitive Level: Application Text Reference: pp. 1044-1045
Nursing Process: Implementation NCLEX: Physiological Integrity

7. A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is
a. "What type of foods do you usually eat?"
b. "Can you tell me about your pain?"
c. "What is your usual elimination pattern?"
d. "Is it possible that you are pregnant?"

Answer: B
Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most.

Cognitive Level: Application Text Reference: p. 1044
Nursing Process: Assessment NCLEX: Physiological Integrity

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