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A client has a total gastrectomy. The nurse explains to the client the need for long-term injections of which of the following vitamins? 1. Thiamine
2. Folic Acid
3 The loss of parietal cells that secrete intrinsic factor results in vitamin B12 (cyanocobalamin) deficiency post gastrectomy, because intrinsic factor is needed for absorption of vitamin B12. For this reason, clients require vitamin B12 injections for life. The other options identify other B-complex vitamins
Core issue: Knowledge that gastric surgery results in loss of ability to produce intrinsic factor and subsequent vitamin B12 deficiency.
A client with diverticular disease undergoes a colonoscopy. When conducting an abdominal assessment, the nurse looks for which of the following as a sign of possible complication?
2. Nausea and vomiting
3. Guarding and rebound tenderness
4. Redness and warmth of the abdominal skin
3 Bowel perforation is a possible result of a colonoscopy if the colonoscope accidentally pierces the bowel wall. Perforation could lead to symptoms of periotonitis, such as guarding and rebound tenderness. The other options are incorrect because 1,2 are signs of obstruction and 4 is not of concern.
Core issue: Assessment data that correlates with complications of colonoscopy, such as peritonitis.
The client who has ulcerative colitis is scheduled for an ileostomy. When the client asks the nurse what to expect related to bowel function and care after surgery, what response should the nurse make?
1. "You will be able to have some control over your bowel movements."
2. "The stoma will require that you wear a collection device all the time."
3. "After the stoma heals, you can irrigate your bowel so you will not have to wear a pouch."
4. "The drainage will gradually become semisolid and formed."
2 A client with an ileostomy has no control over bowel movements and must always wear a collections device. The drainage tends to be liquid but becomes pastelike with intake of specific foods.
Core issue: Knowledge of stool characteristics and associated stoma appliance needs following ileostomy
The nurse is conducting dietary teaching with a client who has dumping symdrome. The nurse encourages the client to avoid which of the foods that the client usually enjoys?
3 Dumping syndrome, in which gastric contents rapidly enter the bowel, can occur following gastrectomy. Dietary fats and proteins are increased, and carbohydrates such as fruits, are reduced. This helps slow the GI transit time and reduce the GI cramping, diarrhea, and vasomotor symptoms associated with dumping syndrome.
Core issue: Knowledge of foods to avoid when the client has dumping syndrome.
A client is being evaluated for possible duodenal ulcer. The nurse assess the client for which of the following manifestations that would support this diagnosis?
1. Epigastric pain relieved by food
2. History of chronic aspirin use
3. Distended abdomen
4. Positive fluid wave
1 The pain of a gastric ulcer is dull and aching, occurs after eating, and is not relieved by food as is the pain from a duodenal ulcer. The pancreatic juices that are high in bicarbonate are released with food intake and relieve duodenal ulcer pain when the client eats. Chronic aspirin use is irritating to the stomach. The manifestations in 2,3 are unrelated.
Core issue: Expected assessment findings in duodenal ulcer. Recall the effect of pancreatic juices on the duodenal ulcer surface and use the process of elimination to make a selection.
The client returning from a colonoscopy has been given a diagnosis of Crohn's disease. The oncoming shift nurse expects to note which of the following manifestations in the client?
2. Firm, rigid abdomen
4. Enlarged hemorrhoids
1 Steatorrhea is often present in the client with Crohn's disease. Diarrhea is also key feature, but unlike ulcerative colitis, the loose stool usually does not contain blood and is usually less frequent in number of episodes.
Core issue: Knowledge and identification of common symptoms of Crohn's disease.
A client is scheduled for a fecal fat exam. In planning client education, the nurse includes that which dietary modification is necessary before the test?
1. Eat a fat-free diet the day before the exam
2. Eat a high-fat meal right before the exam.
3. Eat a diet containing 35 grams of fat for 36 hours before the test.
4. Eat at least 100grams of fat for 3 days before and during the test.
4 It is suggested that adults consume at least 100 grams of fat per day for 3 days prior to test and throughout specimen collection. The other responses provide incorrect information.
Core issue: Ability to provide correct information when teaching a client about proper preparation for fecal fat examination.
The client with diverticular disease is scheduled for a sigmoidoscopy. He suddenly complains of severe abdominal pain. On examination, the nurse notes a rigid abdomen with guarding. What action should the nurse take next?
1. Notify the physician
2. Place the client in a more comfortable position
3. Keep the client distracted until the procedure begins
4. Tell the client that the test will show what is causing his problem
1 Perforation of an obstructed diverticulum can cause abscess formation or generalized peritonitis. The manifestations of peritonitis are abdominal guarding and rigidity and pain.. Sigmoidoscopy is contraindicated in cases of perforation. Because treatment of this complication is beyond the scope of independent nursing practice, the physician must be notified.
Core issue: Ability to identify the occurrence of peritonitis as a complication of diverticular disease and determine the appropriate course of action.
The nurse is educating the client with gastroesophageal reflux disease (GERD) about ways to minimize symptoms. Which information in the client's history should the nurse address as an indicator that needs to be changed?
1. Lifting weights for exercise
2. Being a vegetarian
3. Having a body mass index of 23
4. Taking calcium carbonate tablets
1 Lifestyle modifications can minimize symptoms of GERD. Anything that increases intra-abdominal pressure should be avoided, such as lifting weights. Obesity also aggravates symptoms, but a body mass index of 23 is normal. Being a vegetarian does not increase risk, and calcium carbonate tablets often aid in symptom relief.
Core issue: Ability to identify risk factors that aggravate GERD.
The client with a duodenal ulcer asks the nurse why an antibiotic is part of the treatment regime. Which information should the nurse include in the response?
1. Antibiotics decrease the likelihood of infection
2. Many duodenal ulcers are caused by the Helicobacter pylori organism
3. Antibiotis are used in an attempt to sterilize the stomach
4. Many people have Clostridium difficile, which can lead to ulcer formation
2 H. pylori infection is a major cause of peptic ulcers. Treatment includes eradicating H. pylori with antibiotics. The other answers are incorrect.
Core issue: Knowledge of etiology of peptic ulcers, including duodenal ulcers.
The nurse should evaluate results of which of the following to plan for safe care?
1. Prothrombin time
3. Serum lipase
4. Serum troponin
1 Many clotting factors are produced in the liver, including fibronigen (factor I), prothrombin (factor II), factor V, serum prothrombin conversion accelerator (factor VII), factor IX, and factor X. The client's ability to form these factors may be impaired with cirrhosis, putting the client at risk for bleeding. The prothrombin time will evaluate blood clotting ability, the others will not.
Core issue: The critical word in the questions is "safe". With this in mind, the correct answer is one that could lead to detect a complication of cirrhosis.
The nurse is caring for a client with a history of alcoholism. Which of the following findings would indicate that the client has possibly developed chronic pancreatitis?
1. Steady weight gain
2. Flank pain on the left side only
3. Fatty stools
4. Excessive hunger
3 Manifestations of chronic pancreatitis include vomiting, nausea, weight loss, flatulence, constipation, and steatorrhea that result from a decreases in pancreatic enzyme secretion. Weight gain is the opposite of what occurs with this disorder, while options 2 and 4 are unrelated.
Core issue: Ability to identify assessment findings that are consistent with the development of chronic pancreatitis.
The nurse caring for a client with hemolytic jaundice anticipates which of the following findings on the laboratory results?
1. Elevated serum indirect bilirubin
2. Decreases serum protein
3. Elevated urine bilirubin
4. Decreased urine pH
1 Hemolytic jaundice is caused by excessive breakdown of red blood cells, and the amount of bilirubin produced exceeds the ability of the liver to conjugate it, so there is an increase in indirect bilirubin. Unconjugated bilirubin is insoluble in water and is not found in the urine
Core issue: Knowledge of clinical indicators of hemolytic jaundice.
A client was admitted to the hospital with cholelithiasis the previous day. Which of the following new assessment findings indicates to the nurse that the stone has probably obstructed the common bile duct?
2. Elevated cholesterol level
3. Right upper quadrant (RUQ) pain
4 Nausea and RUQ pain occur in cystic duct disease, but obstruction of the common bile duct results in reflux of bile into the liver, which produces jaundice. alkaline phosphatase increases with biliary obstruction but cholesterol level does not increase.
Core issue: Knowledge of clinical indicators of common bile duct obstruction. Think about the pathophysiology of blocked bile drainage and use the process of elimination to make a decision.
The nurse caring for a client with uncomplicated cholelithiasis anticipates that the client's laboratory test results will show an elevation in which of the following?
1. Serum amylase
2. Alkaline phosphatase
3. Mean corpuscular hemoglobin concentration (MCHC)
4. Indirect bilirubin
2 Obstructive biliary disease causes a significant elevation in alkaline phosphatase. Obstruction in the biliary tract causes an elevation in direct bilirubin, not indirect bilirubin. Options 1 and 3 are unrelated
Core issue: Use nursing knowledge and process of elimination to make a selection
In caring for the client 4 days post-cholecystectomy, the nurse notices that the drainage from the T-tube is 600mL in 24 hours. Which is the appropriate action by the nurse?
1. Clamp the tube q2h for 30 minutes
2. Place the patient in a supine position
3. Assess drainage characteristics and notify the physician
4. Encourage an increase fluid intake
3 The T-tube may drain 500mL in the first 24 h and decreases steadily thereafter. If there is excessive drainage, the nurse should further assess the drainage to be able to describe it accurately and notify the physician immediately. Option 1 would be contraindicated and 2 and 4 are of no help
Core issue: Knowledge of appropriate nursing action following notation of excessive T-tube drainage.
The post-cholecystectomy client asks the nurse when the T-tube will be removed. Which of the following responses by the nurse would be appropriate?
1. "When your stool turns to a normal brown color, the tube can be removed"
2. "The tube will be removed at the same time as your staples"
3. "When the tube stops draining, it will be removed"
4. The tube is usually removed the day after surgery"
1 When T-tube drainage declines and the stools return to a normal brown color, the tube can be clamped 1 to 2 hours before and after meals in preparation for tube removal. If the client tolerates clamping, the tube will then be removed.
Core issue: Appropriate timeframe for use of a T-tube following gallbladder surgery
Which of the following assessments made by the nurse could indicate the development of portal hypertension in a client with cirrhosis?
2. Bleeding gums
3. Muscle wasting
1 Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels predominantly in the paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Bleeding gums would indicate insufficient vitamin K production in the liver. Muscle wasting commonly accompanies the poor nutritional intake commonly seen in clients with cirrhosis. Hypothermia is an unrelated finding.
Core issue: Knowledge of associated findings in a client with portal hypertension
The nurse is caring for a client who has ascites and the health care provider prescribes spironolactone (Aldactone). The client asks why this drug is being used. Which is the best response by the nurse?
1. "This drug will help increase the level of protein in your blood"
2. "The drug will cause an increase in the amount of hormone aldosterone your body produces"
3. "This medication is a diuretic but does not make the kidneys excrete potassium"
4. "This will help you excrete larger amounts of ammonia"
3 Spironolactone (Aldactone) is used in clients with ascites that show no improvement with bedrest and fluid restriction. It inhibits sodium reabsorption in the distal tubule and promotes potassium retention by inhibiting aldosterone. The other options do not address this rationale.
Core issue: Knowledge of medication effects in a client with ascites.
When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding?
1. "Trousseau's sign noted"
2. "Caput medusa noted"
3. "Fetor hepaticus noted"
4. "Asterixis noted"
4 Asterixis, also called liver flap, is the flapping tremor of the hands when the arms are extended. Option 1 reflects hypocalcemia. Option 2 refers to spiderlike abdominal veins that are also commonly found in clients with cirrhosis who have portal hypertension as a complication. Option 3 is a specific odor noted in liver failure
Core issue: Knowledge of typical assessment findings in a client with cirrhosis.
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