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Life Span Chapter 32
Terms in this set (44)
A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy. Which finding should cause the nurse to clarify routine preparation orders with the physician?
Presence of severe diarrhea
The nurse is caring for a patient who is placed on a modified bland diet. Which should be removed before serving the patient's dinner tray?
The nurse is preparing to initiate a tube feeding through a patient's nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube?
The nurse is inspecting a patient's oral cavity. What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient?
Loose teeth can be aspirated into the airway.
The nurse is collecting data from a patient who is scheduled for an ileostomy. Which technique should the nurse use to help identify optimal stoma placement?
A licensed practical nurse (LPN) who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN). Which action should the nurse take?
Notify the charge nurse that an adjustment in the patient assignment is necessary.
The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used?
The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take?
Irrigate the NG tube with 30 milliliters of normal saline
A patient receiving 70 mL of tube feeding per hour has a residual amount of 120 mL. What action should the nurse take?
Hold the feeding, and notify the physician
The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding?
Hypoactive bowel sounds
A patient receiving a tube feeding at 60 mL/hr has a residual of 10 mL. What action should the nurse take?
Continue the feeding as ordered
While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level. How should the nurse interpret this test result?
The patient has a residual or recurrent tumor.
The nurse is reinforcing teaching for a patient who is scheduled for an upper GI series. Which patient statement indicates teaching has been effective?
"It is an x-ray of the esophagus, stomach, and duodenum using barium."
A patient is being prepared for an upper GI series. Which statement indicates that the patient understands the preparation for this test?
"I can't have anything to eat or drink for 6 to 8 hours before the procedure."
The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which action should the nurse take?
Place the patient in high Fowler's position
The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose. What action should the nurse take before starting the feeding?
Check the pH of gastric aspirate.
The nurse is caring for a patient with cultural dietary needs. Which question should the nurse include in a cultural dietary assessment?
"Which foods do you most commonly eat?"
A patient receiving tube feedings at 50 mL/hour has a residual volume of 250 mL of undigested tube feeding. What action should the nurse take?
Report amount of aspirated tube feeding to the RN for consultation with the physician.
The nurse is reviewing GI function with a patient. Which body structure should the nurse emphasize as accomplishing mechanical digestion in the stomach?
Smooth muscle layers
The nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding about the function of hydrochloric acid in gastric juice?
Destruction of pathogens
The nurse is caring for a patient who has a non-vented nasogastric tube. Which suction setting should the nurse select?
Low intermittent suction
The nurse is assisting with the care of a patient who has PN infusing. Which data should be the most concerning to the nurse?
Blood glucose 260 mg/dL
The nurse is assisting with the care of a patient who has PN containing dextrose 50% infusing. The patient asks why the rate keeps being increased. How should the nurse respond to this patient?
"It is started slowly and increased slowly to allow your pancreas to adjust insulin levels."
The nurse is caring for a patient who has a permanent gastric feeding tube. What nursing action would be most helpful to prevent aspiration during feedings?
Elevate head of bed at least 30 degrees.
A patient's Levin NG tube inserted for decompression of the bowel, which is connected to low intermittent suction, is not draining. The patient reports feeling full, uncomfortable, and nauseous. After verifying tube placement, what action should the nurse take next?
Gently irrigate tube with normal saline.
The nurse is reinforcing teaching for a patient who is scheduled for an esophagogastroduodenoscopy. Which patient statement indicates understanding of pre-procedure diet instructions?
"I will have nothing to eat or drink 8 to 12 hours before the procedure."
The nurse is preparing a patient for an NG tube insertion. To decrease the patient's anxiety about insertion of a nasogastric tube, what should the nurse do?
Explain the procedure
The nurse is caring for a patient on a clear liquid diet. The nurse should recognize that the patient requires further teaching if the patient requests which food?
Coffee with cream
The nurse is caring for a patient on a full liquid diet. The nurse recognizes that the patient understands teaching if the patient requests which food item?
A patient recovering from GI surgery 4 hours ago is alert and oriented and complains of feeling thirsty. Diet orders read, "clear liquids, advance as tolerated." Which action should the nurse take?
Allow the patient to take small sips of water.
A patient is prescribed PN. For which percentage of dextrose should the nurse prepare the patient to have a central venous catheter placed for this infusion?
The nurse is palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant. How deep should the nurse depress this patient's abdomen?
While assessing a patient's abdomen, the nurse notes a yellow-tinge to the skin. How should the nurse document this finding?
The nurse is reinforcing teaching for a patient who is on a clear liquid diet. Which patient statement(s) indicates correct understanding of the foods that would be appropriate on this diet? (Select all that apply.)
a. Beef broth
c. Apple juice
d. Orange gelatin
e. Tea with sugar
The nurse is contributing to the teaching plan for another nurse's team of patients. Which patients should the nurse expect to be scheduled for an upper GI series? (Select all that apply.)
a. A 45-year-old with a suspected hiatal hernia
c. A 52-year-old with a family history of polyps
f. A 33-year-old who is experiencing symptoms of pyloric stricture
The nurse is contributing to a patient's plan of care. Which patients should the nurse recommend as benefiting from PN? (Select all that apply.)
a. A patient who has esophageal cancer
e. A patient with severe burns across the face and chest
The nurse is reinforcing teaching for a patient who has hepatitis. Which functions of the liver should the nurse include in the teaching? (Select all that apply.)
a. Form bilirubin
c. Synthesize clotting factors
f. Phagocytize worn red blood cells
The nurse is reinforcing teaching provided to a patient who has a small bowel obstruction. Which processes occur in the small intestine that should be included in this teaching? (Select all that apply.)
e. Production of enzymes to complete carbohydrate metabolism
f. Production of peptides to complete the digestion of proteins to amino acids
The nurse is reviewing structures within the hepatobiliary system with a patient with liver disease. Which structures should the nurse identify as being a part of this system? (Select all that apply.)
d. Bile duct
The nurse is participating in a local health fair. Which should the nurse include in a presentation on aging changes associated with the GI system? (Select all that apply.)
a. Decreased peristalsis
b. Increased constipation
c. Decreased sense of taste
d. Increased periodontal disease
A patient is diagnosed with liver failure. Which vitamin supplements should the nurse expect to be prescribed for this patient? (Select all that apply.)
b. Vitamin D
c. Vitamin K
e. Vitamin B12
A patient is upset to learn that an occult blood test of a stool specimen was positive for blood. What should the nurse assess in this patient to determine if the results were falsely positive? (Select all that apply.)
a. Ingestion of fish
b. Use of aspirin or NSAIDs
d. Ingestion of red meat three days before the test
e. Recent dental procedure causing bleeding gums
The nurse is caring for a patient recovering from an endoscopic retrograde cholangiopancreatography (ERCP). Which findings should the nurse report to the charge nurse immediately? (Select all that apply.)
a. Nausea and vomiting
b. Onset of a fever and chills
d. Heart rate of 110 beats per minute
e. Increased right upper quadrant pain
The nurse is caring for a patient of Mexican American descent who is experiencing diarrhea. Which foods should the nurse expect the patient to select for the next day's meals? (Select all that apply.)
e. Fresh Fruit
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