journal article Show The American Journal of Nursing Vol. 97, No. 7 (Jul., 1997) , pp. 38-46 (9 pages) Published By: Lippincott Williams & Wilkins https://doi.org/10.2307/3465459 https://www.jstor.org/stable/3465459 Read and download Log in through your school or library Journal Information The American Journal of Nursing (AJN) is the oldest and largest circulating nursing journal in the world. The Journal's mission is to promote excellence in professional nursing, with a global perspective, by providing cutting edge, evidence-based information that embraces a holistic perspective on health and nursing. Clinical articles focus on acute care, health promotion and prevention, rehabilitation, emergencies, critical care, home health care, etc. Columns present additional perspectives on clinical care, such as ethics, the law, practice errors, pain and symptom management, and professional issues. 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A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the healthcare provider? A. Flatulence B. Rectal bleeding C. Mild abdominal pain D. Borborygmi B. Rectal bleeding Bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Mild abdominal pain (usually gas pain) and flatulence are expected findings after a sigmoidoscopy. Borborygmi may be heard, especially if the client is hungry if they have followed a clear liquid diet prep before the procedure. The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency? A. Hydrochloric acid B. Intrinsic factor C. Glucagon D. Pepsinogen B. Intrinsic Factor Intrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia. Glucagon, which is produced by the alpha cells in the pancreas, is essential for the regulation of metabolism. Parietal cells secrete hydrochloric acid, but this does not facilitate the absorption of vitamin B12. Pepsinogen is secreted by the chief cells; pepsinogen is a precursor to pepsin, a digestive enzyme. The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has returned? A. Ask if the client has passed flatus (gas) within the previous 12 to 14 hours. B. Perform auscultation with the diaphragm of the stethoscope. C. Listen for bowel sounds in all abdominal quadrants. D. Count the number of bowel sounds in each abdominal quadrant over 1 minute. A. Ask if the client has passed flatus (gas) within the previous 12 to 24 hours. The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours. (Although auscultation and counting the number of sounds can help to assess for bowel activity, it is not the most reliable method). Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? (select all that apply) A. Smoking a half-pack of cigarettes per day B. Taking non steroidal anti-inflammatory drugs (NSAIDS) C. Financial concerns D. Eating a high-fiber diet E. Use of herbal preparations A (Tobacco) B (NSAIDS can predispose to PUD or GI bleeds) C (Stress, risk for GI issues) E (tobacco) A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (select all that apply). A. Percuss to determine size of liver and spleen. B. Auscultate beginning in the RLQ. C. Visually observe for contour and symmetry. D. Ask for a pain scale rating on a scale of 0-10. E. Deeply palpate the area of tenderness. B (assess) D (assess) The abdominal assessment is performed in the order of inspection, auscultation, percussion, and palpation. The nurse will visually observe the abdomen for contour and symmetry, auscultate beginning in the RUQ (not the RLQ), lightly palpate for any large masses or areas of tenderness, ask the client to rate the pain level on a 0-10 scale, and document the findings. The nurse will not perform deep palpation nor percussion, as the health care provider conducts this portion of the examination. Indication of abnormal lab findings in Liver Disease: Elevated serum aspartate amino transferase (AST) Hepatic cell destruction, hepatitis Indication of abnormal lab findings in Liver Disease: Elevated serum alanine aminotransferase (ALT) Hepatic cell destruction, hepatitis (most specific indicator) Indication of abnormal lab findings in Liver Disease: Elevated lactate dehydrogenase (LDH) Indication of abnormal lab findings in Liver Disease: Elevated serum alkaline phosphate Obstructive jaundice, hepatic metastasis Indication of abnormal lab findings in Liver Disease: Elevated gamma-glutamyl transpeptidase (GGT) Biliary obstruction, cirrhosis Indication of abnormal lab findings in Liver Disease: Elevated serum total bilirubin Indication of abnormal lab findings in Liver Disease: Elevated serum direct conjugated bilirubin Hepatitis, liver metastasis Indication of abnormal lab findings in Liver Disease: Elevated serum indirect unconjugated bilirubin Indication of abnormal lab findings in Liver Disease: Elevated urine bilirubin Hepatocellular obstruction, viral or toxic liver disease Indication of abnormal lab findings in Liver Disease: Elevated urine urobilinogen Indication of abnormal lab findings in Liver Disease: Decreased fecal unobilinogen Obstructive liver disease The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A. My family likes to eat small meals every 3 to 4 hours throughout the day. B. When I buy meat, I ask for the leanest cut that is available. C. I quit smoking 6 months ago. D. Sometimes I wake up gasping for air in the middle of the night. D. Sometimes I wake up gasping for air in the middle of the night. Gasping for air upon waking in the middle of the night can be a sign of sleep apnea; the nurse must report this finding to the primary health care provider. Often patients who have one condition (sleep apnea or GERD) also experience the other. Quitting smoking 6 months ago, eating small meals, and eating lean meats are favorable findings that do not need to be reported. A client reports ongoing episodes of "heartburn." Which food will the nurse recommend that the client eliminate from the diet? A. Steak. B. Carrots. C. Chocolate. D. Popcorn. C. Chocolate. Foods that decrease esophageal sphincter pressure, such as fatty foods, caffeine, and chocolate, should be avoided. Steak, carrots, and popcorn do not decrease esophageal sphincter pressure. The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider? A. My family likes to eat small meals every 3 to 4 hours throughout the day. B. When I buy meat, I ask for the leanest cut that is available. C. I quit smoking 6 months ago. D. Sometimes I wake up gasping for air in the middle of the night. D. Sometimes I wake up gasping for air in the middle of the night. Gasping for air upon waking in the middle of the night can be a sign of sleep apnea; the nurse must report this finding to the primary health care provider. Often patients who have one condition (sleep apnea or GERD) also experience the other. Quitting smoking 6 months ago, eating small meals, and eating lean meats are favorable findings that do not need to be reported. A client reports ongoing episodes of "heartburn." Which food will the nurse recommend that the client eliminate from the diet? A. Steak B. Carrots C. Chocolate D. Popcorn C. Chocolate Foods that decrease esophageal sphincter pressure, such as fatty foods, caffeine, and chocolate, should be avoided. Steak, carrots, and popcorn do not decrease esophageal sphincter pressure. The community nurse is discussing risk factors for esophageal cancer with a group of clients. Which client behavior requires further teaching? A. Eats a small snack each night before bedtime. B. Walks at the shopping mall 3 times weekly. C. Smokes 1/3 of a pack of cigarettes daily. D. Elevates pillows at night. C. Smokes 1/3 of a pack of cigarettes daily. Tobacco use is one of the primary risk factors for esophageal cancer. This client behavior requires teaching about lifestyle risks that could increase the risk for esophageal cancer. Other reported client behaviors are acceptable and do not increase risk for esophageal cancer. The nurse is caring for a client who has been diagnosed with esophageal cancer. The client appears anxious, and asks the nurse, "Does this mean I am going to die?". Which nursing response is appropriate? (select all that apply) A. Let me sit with you for awhile and we can discuss how you are feeling about this. B. You can beat this disease if you just put your mind to it. C. No, surgery can cure you. D. It sounds like death frightens you. E. Let me call the hospital chaplain to talk with you. A. Let me sit with you for awhile and we can discuss how you are feeling about this. D. It sounds like death frightens you. Acknowledging that death may frighten the client, and offering to talk about how the client is feeling, are therapeutic nursing interventions. Telling the client that surgery is curative, and promising the client can beat the disease, are nontherapeutic responses that provide false hope. Although talking with the chaplain at a later time may be requested by the client, the immediate need is to allow the client to express feelings to the nurse. A client has a NGT connected to low continuous suction. What is the nurse's priority to ensure client safety? A. Assess for peristalsis at least once every 8 to 12 hours. B. Assess placement of NGT for placement every 4 hours. C. Measure the gastric drainage every 8 to 12 hrs and document. D. Monitor the nasal skin and membranes around the tube for irritation. B. Assess placement of the NGT for placement every 4 hours. Assessing the NGT for placement every 4 hours can help prevent aspiration which could lead to pneumonia. The other actions are appropriate for some clients, checking tube placement is the priority for care. A client who has colorectal cancer is scheduled for a colostomy. Which referral is initially the most important for this client? A. Home health nursing agency B. Social worker C. Certified wound, ostomy and continence nurse (CWOCN) D. Hospital chaplain C. Certified Wound, Ostomy, and Continence Nurse (CWOCN) A CWOCN (or an enterostomal therapist) will be of greatest value to the client with colorectal cancer because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease. The home health nurse is teaching a client about the care of a new colostomy. Which statement by the client demonstrates a correct understanding of the health teaching? A. If the skin around the stoma is red or scratched, it will soon. B. I need to strive for a very tight fit when applying the barrier around the stoma. C. A dark or purplish-looking stoma is normal and would not concern me. D. I need to check for leakage underneath my colostomy. D. “I need to check for leakage underneath my colostomy.” The client’s statement, “I need to check for leakage underneath my colostomy” shows that the patient correctly understands the instructions about how to care for a new colostomy. The pouch system must be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma must be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma. The nurse is teaching a client with irritable bowel syndrome who has frequent constipation. Which statement by the client shows an accurate understanding of the nurse's teaching? A. Maintaining a low-fiber diet will manage my constipation. B. I need to go for a walk every day if possible. C. Limiting the amount of fluid that I drink with meals is very important. D. A cup of caffeinated coffee with cream & sugar at dinner is OK for me. B. “I need to go for a walk every day if possible.” The client statement, “I need to go for a walk every evening,” shows that the client accurately understands the nurse’s teaching plan to treat IBS. Walking every day is an excellent exercise for promoting intestinal motility. Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages. A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. The client asks whether he will inherit the disease. How would the nurse respond? A. Have you asked your primary health care provider about your chance? B. It is hard to know what can predispose a person to develop a certain disease. C. The only way to know whether you are predisposed to CRC is by genetic testing. D. No. Just because they both had CRC doesn't mean that you will have it too. C. “The only way to know whether you are predisposed to CRC is by genetic testing.” The nurse’s best response to the client who asks if he will inherit CRC is “the only way to know whether you are predisposed to CRC is by genetic testing.” Genetic testing is the only definitive way to determine whether the patient has a predisposition to develop CRC. The certified wound, ostomy and continence nurse (CWOCN) is teaching a client with colorectal cancer how to care for a newly created colostomy. Which statement by the client indicates a correct understanding of the necessary self-management skills? A. If I have any leakage, I'll put a towel over it. B. I can put aspirin tablets in the pouch in order to reduce odor C. I will apply a nonalcoholic skin sealant and let it dry before applying the bag D. I will have my spouse change the bag for me. C. “I will apply a nonalcoholic skin sealant and let it dry before applying the bag.” The nurse would teach the client and family to apply a skin sealant (preferably without alcohol) and allow it to dry before application of the appliance (colostomy bag) to facilitate less painful removal of the tape or adhesive. It is not realistic that the spouse will always change the patient’s bag and does not reflect correct understanding of self-management skills. A towel is not an acceptable or effective way to cope with leakage. Putting an aspirin in the pouch will not reduce odor and can lead to ulcers in the stoma. offers reassurance and is a “pat” statement, making it nontherapeutic. “Why” questions place patients on the defense and are not therapeutic because they close the conversation. A 67-yr old male client with no surgical history reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? A. Reducible B. Strangulated C. Incarcerated D. Femoral A. Reducible The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. An incarcerated or irreducible hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation. A male client is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which statement by the client indicates a need for further teaching about this procedure? A. I may have trouble urinating immediately after the surgery B. My chances of having complications after this procedure are slim. C. I will need to stay in the hospital overnight. D. I will not eat after midnight the day of the surgery. C. “I will need to stay in the hospital overnight.” A need for further teaching about MIIHR is when the patient says, “I will need to stay in the hospital overnight.” Usually, the patient is discharged 3 to 5 hours after MIIHR surgery. Male patients who have difficulty urinating after the procedure would be encouraged to force fluids and to assume a natural position when voiding. Patients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most patients who have MIIHR surgery have an uneventful recovery. The nurse is teaching an older client how to prevent a stool impaction that can obstruct the intestines. Which statement by the client indicates a need for further teaching? A. I will drink lots of fluids every day, especially water. B. I will increase my exercise, especially walking every day. C. I will be sure to take a laxative every night to keep my bowels moving. D. I will try to eat more high-fiber foods, such as raw vegetables and whole grains. C. “I will be sure to take a laxative every night to keep my bowels moving.” All of these statements are correct except that the client should not take laxatives because they can decrease the tone of the abdominal muscles. The nurse is providing teaching on ways to promote bowel health and disease prevention. Which statement will the nurse include in this teaching? A. You should start colorectal cancer screening when you are over 70 years of age. B. You only need to have regular colonoscopies if there is colorectal cancer in your family. C. If you performa fecal occult blood tests every 5 years, you don't need a colonoscopy. D. You should have a colonoscopy every 10 years starting at 45 years of age. D. “You should have a colonoscopy every 10 years starting at 45 years of age.” The American Cancer Society recommends that for individuals of average risk for colorectal cancer (CRC), a colonoscopy every 10 years or flexible sigmoidoscopy every 5 years is adequate. The screening should begin for adults of 45 years of age or older unless individuals are at high risk for CRC. A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. After a complete assessment, what action would the nurse plan implement at this time? A. Change the nasogastric suction level from "intermittent" to "continuous" B. Administer medication for pain based on the client's pain level. C. Position the client in a semi- or high-fowlers position. D. Prepare the client for emergency surgery in collaboration with the health team. Prepare the client for emergency surgery in collaboration with the health team. The appropriate nursing action for a client with intestinal obstruction whose pain changes from “colicky” intermittent type to constant discomfort is to prepare surgery because this change is most likely indicative of perforation or peritonitis and will require immediate surgical intervention. Pain medication may mask the client’s symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client’s pain and could be particularly ineffective if a nonvented tube is in use.
The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which statement by the client demonstrates a correct understanding of the nurse's instructions? A. I will take laxatives after the surgery to 'keep things moving'. B. To help with the pain, I'll apply ice to the surgical area. C. I will need to eat a diet high in fiber, including raw vegetables. D. Limiting my fluids will help me with constipation. C. “I will need to eat a diet high in fiber, including raw vegetables.” The statement that shows that the hemorrhoidectomy patient correctly understands the nurse’s instruction is, “I will need to eat a diet high in fiber.” A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Laxatives are discouraged because they can be habit-forming and decrease abdominal muscle tone. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications. The nurse is caring for a client who had an anterior-posterior surgical resection for colorectal cancer this morning. What will the nurse anticipate as the client's priority problem at this time? A. Intestinal obstruction B. Nausea and vomiting C. Severe pain D. Constipation C. Severe pain The surgical incisions are in the perineal area and are very painful due to the number of nerves in that region of the body. Pain control is the biggest challenge for the nurse and health care team to promote client comfort. The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) A. Yoga B. Acupuncture C. Peppermint oil capsules D. Decreasing physical activities E. Meditation A, B, C, E Possible treatment modalities the nurse suggests for a client with IBS include: acupuncture, meditation, peppermint oil capsules, and yoga. Acupuncture is recommended as a complementary therapy for IBS. Meditation, yoga, and other relaxation techniques help many patients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination. The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods should be avoided? (Select all that apply.) A. Mushrooms B. Peas C. Onions D. Broccoli E. Buttermilk F. Yogurt A, B, C, D Foods the patient with a newly created colostomy needs to limit or avoid because of flatulence or odors include: broccoli, mushrooms, onions, and peas. Buttermilk will help prevent odors. Yogurt can help prevent flatus. The nurse is reviewing medications that can be used for female clients who have constipation-predominant irritable bowel syndrome (IBS). Which drugs are available for this health problem? (Select all that apply.) A. Lubiprostone B. Cetuximab C. 5-fluorouracil D. Psyllium hydrophilic mucilloid E. Linaclotide A, D, E Cetuximab and 5-fluorouracil are chemotherapeutic drugs used for clients who have colorectal cancer. The other drugs are available for female clients who have constipation-predominant IBS. A client with a family history of colorectal cancer (CRC) regularly sees a primary health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? A. Decrease in liver function test results B. Elevated carcinoembryonic antigen C. Negative test for occult blood D. Elevated hemoglobin levels B. Elevated carcinoembryonic antigen Carcinoembryonic antigen may be elevated in many patients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC. A client is admitted to the hospital with right lower quadrant abdominal pain, nausea, and vomiting. What assessment would the nurse monitor to identify a potentially life-threatening complication based on the client’s condition? A. Intake & Output B. Electrolyte values C. Abdominal assessment D. Vital signs Vital signs The client most likely has appendicitis which can result in perforation of the appendix and peritonitis. If this complication occurs, the client would develop tachycardia and a fever. Therefore, the nurse would monitor for changes in vital signs. The nurse is teaching a group of senior citizens in a residential facility about how to prevent gastrointestinal (GI) infectious outbreaks, such as norovirus. What information will the nurse include as a priority intervention for the group? A. Keeping at least 6 feet apart B. Handwashing and hand sanitizing C. Avoiding group dining D. Cooking all food and boiling water B. Handwashing and hand sanitizing GI infections like norovirus are typically transmitted via the fecal-oral route. Therefore, handwashing and using hand sanitizers frequently is the best method to promote health and prevent infection. The nurse is assessing an older client who has had frequent vomiting and diarrhea for the last 24 hours. Which vital sign change would be of most concern to the nurse? A. Increased oxygen saturation B. Decreased blood pressure C. Increased temperature D. Decreased pulse rate B. Decreased blood pressure Older clients are most at risk for dehydration from loss of fluids. Older clients who have dehydration usually have an increased pulse and decreased blood pressure (BP). When BP decreases, the client is at risk for orthostatic hypotension which can cause dizziness and subsequent falls. The client may also experience an elevated temperature, but this change is less common in older adults when compared to their younger counterparts. The nurse is preparing to provide health teaching for a client who is starting sulfasalazine. Which statement by the client indicates a need for further teaching? A. “I’ll let my primary health care provider know if the drug upsets my stomach.” B. “I will be sure to take a folic acid supplement while on this drug.” C. “I will follow up with getting labs done to check my blood counts.” D. “This drug can make me dehydrated because I’m already on a diuretic.” D. “This drug can make me dehydrated because I’m already on a diuretic.” Sulfasalazine can cause nausea and vomiting, and can interfere with folic acid absorption. In high doses, it can also cause anemia and agranulocytosis, so blood work would be important for ongoing monitoring. However, the drug does not cause dehydration. The nurse is teaching a client about caring for a new ileostomy. What information is most important to include? A. “After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present.” B. “Remember that you must wear a pouch system at all times.” C. “Notify the primary health care provider if output from your stoma has a sweetish odor.” D. “Call your primary health care provider if your stoma has a bluish or pale look.” D. “Call your primary health care provider if your stoma has a bluish or pale look.” It is most important for the nurse to tell the client with a new ileostomy to call the primary health care provider if the stoma has a bluish or pale look. If the stoma has a bluish, pale, or dark look, its blood supply may be compromised and the primary health care provider must be notified immediately. A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How would the nurse respond? A. “A change in position may be what is needed for you to have intercourse with your wife.” B. “You must get clearance from your primary health care provider before you attempt to have intercourse.” C. “What has your wife said about your pouch system?” D. “Have you considered going to see a marriage counselor with your wife?” A. “A change in position may be what is needed for you to have intercourse with your wife.” The nurse tells the client who had an emergency ileostomy that a simple change in positioning during intercourse may alleviate apprehension and facilitate sexual relations with his wife. Suggesting marriage counseling may address the client’s concerns, but it focuses on the wrong issue. The client has not stated that he has relationship problems. Asking the client what his wife has said about the pouch may address some of the client’s concerns, but it similarly focuses on the wrong issue. The nurse is reinforcing teaching provided by the registered dietitian nutritionist about dietary restrictions needed for a client who has a new ileostomy. Although each client can tolerate different foods, what food would the nurse suggest that the client avoid? A. Potatoes B. Corn C. Bread D. Green beans B. Corn The client should avoid gas-forming foods like cabbage and foods that contain indigestible fiber such as nuts and corn. A client developed gastroenteritis while traveling outside the country. What is the most likely cause of the client’s symptoms? A. Overcooked food B. Ingestion of parasites in the water C. Insufficient vaccinations D. Bacteria on the patient’s hands B. Ingestion of parasites in the water The likely cause of gastroenteritis when a client travels outside the country is ingestion of water that is infested with parasites. Bacteria on the client’s hands will not produce gastroenteritis unless food or water is contaminated with the bacteria. Insufficient vaccinations may cause other disease processes, but not gastroenteritis. Undercooked, not overcooked, food may produce gastroenteritis. The nurse is caring for a client admitted with a long-term diagnosis of ulcerative colitis (UC). For what potentially life-threatening complication would the nurse monitor? A. Chronic kidney disease B. Lower gastrointestinal (GI) bleeding C. Metabolic acidosis D. Hyperkalemia B. Lower gastrointestinal (GI) bleeding The client who has UC is at most risk for lower GI bleeding due to inflammation and diarrhea. The client with UC is also at risk for hypokalemia and metabolic alkalosis as a result of losing intestinal contents through diarrhea. The nurse is teaching a client with Crohn disease about managing the disease with the adalimumab Which instruction does the nurse emphasize to the client? A. “Do not take the medication if you are allergic to foods with fatty acids.” B. “Avoid large crowds and anyone who is sick.” C. “Monitor your blood pressure and report any significant decrease in it.” D. “Expect difficulty with wound healing while you are taking this drug.” B. “Avoid large crowds and anyone who is sick.” The nurse emphasizes that the client taking adalimumab for Crohn disease needs to avoid being around large crowds to prevent developing an infection. Adalimumab (Humira), a biological response modifier (BRM), also known as a monoclonal antibody drug, has been approved for use in Crohn disease when other drugs have been ineffective. BRMs are approved for refractory (not responsive to other therapies) cases. These drugs cause immunosuppression and should be used with caution. Clients must be taught to report any signs of a beginning infection, including a cold, and to also avoid others who are sick. The client would not take the medication if he or she is allergic to certain proteins. Although immune suppression may occur to some degree, the client would not experience difficulty with wound healing while taking adalimumab. Also, the client would not experience a decrease in blood pressure from taking this drug. The nurse is teaching a client about dietary methods to help manage exacerbations (flare-ups) of diverticulitis. What does the nurse advise the client? A. “Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition.” B. “Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet.” C. “Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet.” D. “Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation.” B. “Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet.” The nurse teaches the client that the most effective way to manage diverticulitis is to consume a low-fiber diet while inflammation is present, followed by a high-fiber diet once the inflammation has subsided. Neither an exclusively low-fiber diet nor an exclusively high-fiber diet will effectively manage diverticulitis. A high-fiber diet while diverticulitis is active will only worsen the disease and its symptoms. A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What intervention would the nurse recommend for the client to do? A. “Avoid all solid foods to allow complete bowel rest.” B. “Take an over-the-counter antidiarrheal medication.” C. “Contact your primary health care provider for an antibiotic medication.” D. “Consume extra fluids to replace fluid losses.” D. “Consume extra fluids to replace fluid losses.” The nurse tells the client to drink extra fluids to replace fluid lost through vomiting and diarrhea. It is not necessary to stop all solid food intake. Antidiarrheal medications are used if diarrhea is severe. Antibiotics are used if the infection is bacterial. A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after being situated in bed? A. Semi-Fowler B. Lateral Sims’ (side-lying) C. High Fowler D. Supine A. Semi-Fowler The nurse places the postoperative abdominal laparotomy client in the semi-Fowler position in bed. The client is maintained in this position to facilitate the drainage of peritoneal contents into the lower region of the abdominal cavity after an abdominal laparotomy. This position also helps increase lung expansion. High-Fowler position would be too high for the client postoperatively. It would place strain on the abdominal incision(s), and, if the client was still drowsy from anesthesia, this position would not enhance the client’s ability to rest. Sims’ position does not promote drainage to the lower abdomen. The supine position does not facilitate drainage to the abdomen or increased lung expansion. The client would be more likely to develop complications (wound drainage stasis and atelectasis) in the supine position. A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? A. “Raw vegetables and high-fiber foods may help to diminish your symptoms.” B. “Lactose-containing foods should be reduced or eliminated from your diet.” C. “Drinking carbonated beverages will help with your abdominal distress.” D. “It’s OK to smoke cigarettes, but you should limit them to ½ pack per day.” B. “Lactose-containing foods should be reduced or eliminated from your diet.” The nurse teaches the newly diagnosed client with ulcerative colitis that lactose-containing foods are often poorly tolerated and need to be reduced or eliminated from the diet. Carbonated beverages are GI stimulants that can cause discomfort and must be used rarely or completely eliminated from the diet. Cigarette smoking is a stimulant that can cause GI distress symptoms. Nurses would never advise patients that any amount of cigarette smoking is “OK.” Raw vegetables and high-fiber foods can cause GI symptoms in patients with UC. The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A. A slice of 5-grain bread B. Strawberries (1 cup [160 g]) C. Tomato (1 medium) D. Chuck steak patty (6 ounces [170 g]) A. A slice of 5-grain bread The nurse suggests to the client with recently diagnosed diverticular disease to include a slice of 5-grain bread in the diet. Whole-grain breads are recommended to be included in the diet of clients with diverticular disease because cellulose and hemicellulose types of fiber are found in them. Dietary fat would be reduced in clients with diverticular disease. If the client wants to eat beef, it must be of a leaner cut. Foods containing seeds, such as strawberries, must be avoided. Tomatoes would also be avoided unless the seeds are removed. The seeds may block diverticula in the patient and present problems leading to diverticulitis. An older client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which primary health care provider request does the nurse implement first? A. Obtain a stool specimen for culture and sensitivity. B. Start an IV solution of 5% dextrose in 0.45 normal saline. C. Draw blood for a complete blood count and serum electrolytes. D. Administer acetaminophen 650 mg rectally. B. Start an IV solution of 5% dextrose in 0.45 normal saline. The request the nurse implements first is to start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr. Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Fluid therapy is the focus of treatment for clients with gastroenteritis. Older clients are at increased risk for the complications of dehydration such as hypovolemia and acute kidney failure. Acetaminophen 650 mg should be administered rectally soon, and blood draws and stool specimen collection would also be implemented soon, but prevention and treatment of dehydration are the priorities for this client. A client with ulcerative colitis (UC) is prescribed sulfasalazine and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client’s medication regimen? A. Corticosteroid therapy will be tapered. B. Corticosteroid therapy will be stopped. C. Sulfasalazine will be stopped. D. Sulfasalazine will be tapered. A. Corticosteroid therapy will be tapered. The nurse expects that corticosteroid therapy will be tapered as the UC improves in the client who was taking both sulfasalazine and corticosteroids. Once clinical improvement has been established, corticosteroids are tapered over a 2- to 3-month period. Stopping corticosteroid therapy abruptly is unsafe—steroids must be gradually decreased in patients. Usually the amount that they have been taking dictates how quickly or slowly they can be stopped. Sulfasalazine therapy will be taken on a long-term basis. It may be increased or decreased, depending on the patient’s symptoms, but will likely never be stopped. These decisions are made over a long period of therapy. The nurse is preparing to administer natalizumab for a client who has Crohn disease (CD). What is the most important client assessment for the nurse to perform before giving this drug? A. Skin integrity B. Body temperature C. Peripheral pulses D. Breath sounds B. Body temperature Because this drug may cause a deadly infection that affects the brain (progressive multifocal leukencephalopathy [PML]), the nurse would want to ensure that the client does not have any type of infection. Assessing body temperature is one way to determine the presence of infection. The nurse is caring for a client who has an enterocutaneous fistula. For what complications will the nurse monitor? (Select all that apply.) A. Skin breakdown B. Hyperkalemia C. Malnutrition D. Hypernatremia E. Dehydration F. Bowel obstruction A, C, D The client has an abnormal tunneling between the small intestines and the skin causing spillage of the GI contents onto the skin. Enzymes in the intestines can break down skin and underlying tissues. The intestinal contents are also rich in fluids and electrolytes, especially potassium, such that the client would likely develop hypokalemia rather than hyperkalemia. Loss of fluids could lead to dehydration if the client is not carefully monitored and managed. The nurse is teaching a family how to prevent the client’s transmission of gastroenteritis at home. Which instructions will the nurse include in the health teaching? (Select all that apply.) A. “Clean and disinfect all bathrooms often to avoid stool exposure.” B. “Everyone in the home should wash their hands for at least 30 seconds with an antibacterial soap using friction.” C. “Contact the primary health care provider if GI symptoms last more than 3 days.” D. “Wear a mask at home to prevent transmission of the disease.” E. “Do not share dishes, glasses, and silverware among members of the family.” A, B, C, E All of these interventions are important to prevent the spread of gastroenteritis except there is no need to wear a mask because the disease is spread via the fecal-oral route rather than by droplets. Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? A. “The scars on my liver create problems with blood circulation.” B. “My liver is scarred, but the cells can regenerate themselves and repair the damage.” C. “Because of the scars on my liver, blood clotting and blood pressure are affected.” D. “Cirrhosis is a chronic disease that has scarred my liver.” B. “My liver is scarred, but the cells can regenerate themselves and repair the damage.” The client’s statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage. The nurse is caring for a client who has cirrhosis of the liver. The client’s latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor: A. Deep vein thrombosis. B. jaundice. C. hematemesis. D. pressure injury. C. hematemesis. The client who has cirrhosis is at risk for bleeding due to decreased production of prothrombin by the liver. Portal hypertension that occurs in clients with cirrhosis causes esophageal blood veins to become fragile, distended, and tortuous. Therefore, these veins tend to bleed as evidenced by either hematemesis or melena. How would the home care nurse best modify the client’s home environment to manage side effects of lactulose? A. Obtains a walker for the client. B. Rearranges furniture to declutter the home. C. Removes throw rugs to prevent falls. D. Requests a bedside commode for the client. D. Requests a bedside commode for the client. The home care nurse would modify the client’s home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet. When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? A. Assist the provider to insert a trocar catheter into the abdomen. B. Position the client with the head of the bed flat. C. Encourage the client to take deep breaths and cough. D. Ask the client to void prior to the procedure. D. Ask the client to void prior to the procedure. To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure. Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder. The nurse is caring for a client who was recently diagnosed with Laennec cirrhosis. What is the nurse’s priority assessment during client care? A. Cardiovascular assessment B. Abdominal assessment, including bowel sounds C. Respiratory assessment D. Cognitive and neurologic assessment D. Cognitive and neurologic assessment The type of cirrhosis that this client has is caused by alcoholism. Withdrawal from alcohol can cause cognitive and neurologic changes, such as confusion and delirium tremens (DTs). The nurse collaborates with the registered dietitian nutritionist in providing teaching for a client who has ascites from cirrhosis. What daily dietary restriction would the nurse include in the health teaching? A. Calcium B. Potassium C. Magnesium D. Sodium D. Sodium Mild to moderate sodium restriction is often tried as the first intervention to decrease body fluid retention, including ascites. The nurse is caring for a client who just had a paracentesis. Which client finding indicates that the procedure was effective? A. Increased blood pressure B. Decreased weight C. Increased pulse D. Decreased pain B. Decreased weight A paracentesis is performed to remove ascitic fluid from the abdomen. Therefore, the client should weigh less after the procedure than before. Blood pressure should decrease due to less fluid volume and the pulse rate may not be affected. The client may report less abdominal discomfort or ease in breathing, but pain is not a common problem for cirrhotic clients. Which action by the nurse would most likely help to relieve symptoms associated with ascites? A. Monitoring serum albumin levels B. Lowering the head of the bed C. Administering oxygen therapy D. Administering intravenous fluids C. Administering oxygen therapy The best action by the nurse caring for a client with ascites is to elevate the head of the bed and provide supplemental oxygen. The enlarged abdomen of ascites limits respiratory excursion. Fowler position will increase excursion and reduce shortness of breath. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites. The nurse is teaching a client and family about home care following a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. Which client finding would the nurse teach the family to report to the primary health care provider immediately? A. Decreased ascitic fluid B. Changes in consciousness or behavior C. Fatigue and weakness D. Decreased pulse rate B. Changes in consciousness or behavior Although serious complications of the TIPS are not common, the client needs to be monitored for hepatic encephalopathy. This complication is manifested by changes in consciousness, mental status, and/or behavior. A decreased pulse rate and ascitic fluid are expected and clients with cirrhosis are usually fatigued and weak. The family of a client who has hepatic encephalopathy asks why the client is restricted to moderate amounts of dietary protein and has to take lactulose. What is an appropriate response by the nurse? A. “These interventions help to reduce the ammonia level.” B. “These interventions help to prevent heart failure.” C. “These interventions help the client’s jaundice improve.” D. “These interventions help to prevent nausea and vomiting.” A. “These interventions help to reduce the ammonia level.” The client’s high ammonia level has caused encephalopathy which can become so severe that it causes death. These interventions help to reduce ammonia in the body so that this condition does not worsen. The nurse is assessing a client who is diagnosed as having Hepatitis A and asks how someone gets this disease. What is the most likely cause of the client’s Hepatitis A? A. Being exposed to blood or blood products B. Eating contaminated food or water C. Having unprotected sex D. Sharing needles for illicit drugs B. Eating contaminated food or water Hepatitis A is transmitted through the fecal-oral route rather than via blood. Therefore, contaminated food or water with Escherichia coli or other microbes can cause this liver infection. When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? A. Clients who work with shellfish. B. Clients with elevations of aspartate aminotransferase and alanine aminotransferase. C. Men who engage in sex with men. D. Clients traveling to a third-world country. C. Men who engage in sex with men. Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A. Hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B. It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? A. Right shoulder pain B. Bone marrow suppression C. Polyuria D. Bleeding D. Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority. Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators is used, the nurse then assesses for bone marrow suppression. What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A. Drink only bottled water and avoid ice. B. Avoid sharing the bathroom with the client. C. Members of the household must not share toothbrushes. D. The client must not consume alcohol. C. Members of the household must not share toothbrushes. The nurse teaches the family of a client with hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water needs to be avoided. The nurse is caring for a client who had a liver transplant last week. For which complication will the nurse teach the client and family to monitor? A. Acute kidney injury B. Hypertension C. Pulmonary edema D. Infection D. Infection The client is at the most risk for rejection of the transplant which can be the result of an infection if not identified and managed effectively. Therefore, the nurse would teach the client and family to report cough, fever, skin redness, and other signs of infection. When caring for a client with Laennec cirrhosis, which of these findings does the nurse expect to find on assessment? (Select all that apply.) A. Elevated Magnesium B. Swollen abdomen C. Prolonged partial thromboplastin time D. Elevated amylase level E. Currant jelly stool F. Icterus of skin B, C, F Clients with Laennec cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase. When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.) A. Right upper quadrant tenderness B. Itching C. Recent influenza infection D. Brown stool E. Tea-colored urine A, B, E Assessment findings the nurse expects to find in a client with hepatitis B include brown, tea-, or cola-colored urine; right upper quadrant pain due to inflammation of the liver; and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored, not typically brown. When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.) A. Esophageal varices B. Ascites C. Hematuria D. Hemorrhoids E. Fever A, B, D Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process. The nurse teaches the client who has cirrhosis about foods and other substances that should be avoided to prevent worsening of the disease. Which substance(s) will the nurse include in that health teaching? (Select all that apply.) A. Smoking B. Alcohol C. Illicit drugs D. Acetaminophen E. Sodium F. Protein A, B, C, D Protein and sodium should be moderately restricted but not completely avoided. The other substances can worsen the disease process, especially drugs and alcohol which are normally metabolized by the liver. The nurse is caring for a client who has been diagnosed with cirrhosis. Which laboratory result(s) would the nurse expect for this client? (Select all that apply.) A. Increased serum bilirubin B. Increased lactate dehydrogenase C. Decreased serum albumin D. Increased serum alanine aminotransferase E. Increased aspartate aminotransferase F. Increased serum ammonia A, B, C, D, E, F Cirrhosis is a chronic disease in which the liver progressively degenerates. As a result, liver enzymes and bilirubin increase. Additionally, the liver is unable to synthesize protein leading to decreased serum albumin. Elevated serum ammonia results from the inability of the liver to detoxify protein by-products. The nurse is caring for a client who states that her mother had “gallbladder problems” and wonders if she is at risk for this disorder. What major risk factor places women most at risk for gallbladder disease? A. Obesity B. Birth control pills C. Infertility D. Advanced age A. Obesity Obese women who are middle age and have had multiple children are at the highest risk for gallbladder disease, although it can occur in anyone. A client is preparing to have a hepatobiliary scan (HIDA scan). What health teaching would the nurse include about what the client can expect during the test? A. “This test measures how inflamed your gallbladder and liver may be.” B. “You may eat and drink as much as you’d like before you have this test.” C. “You will have to lie still for some time while the camera is very close to your body.” D. “I need to know if you are allergic to shellfish because the contrast will be iodine-based.” C. “You will have to lie still for some time while the camera is very close to your body.” The HIDA scan requires the injection of radioactive medium which is given about 20 minutes before a large camera is positioned very close to the body. The camera moves to assess for biliary flow and to determine if any obstruction is present. The nurse is caring for a client who recently had an external percutaneous transhepatic biliary catheter placed for severe biliary obstruction. What is the nurse’s priority intervention when caring for this client? A. Keeping the biliary drainage bag below the level of the catheter-insertion site B. Checking the client’s blood glucose frequently to monitor for diabetes C. Managing pain with continuous opioid patient-controlled analgesia (PCA) D. Capping the catheter if it starts to leak around the insertion site A. Keeping the biliary drainage bag below the level of the catheter-insertion site The client who has an external percutaneous transhepatic biliary catheter drains by gravity and therefore needs to have the drainage bag placed lower that the catheter-insertion site. The catheter is not capped if jaundice or leakage around the catheter site occurs. Opioids are not needed while the client has the catheter; however, if it is in place for an extended period of time, it needs to be changed. The nurse is teaching a preoperative client who is scheduled for a laparoscopic cholecystectomy (“lap chole”). What statement by the client indicates a need for further teaching? A. “I will likely need oral pain medications for the first few days after my surgery.” B. “I should only be hospitalized for 2 to 3 days after my surgery.” C. “I will probably not be at risk for complications from this surgery.” D. “I should be able to go back to work in the next week or so.” B. “I should only be hospitalized for 2 to 3 days after my surgery.” A “lap chole” surgery has many advantages over the open traditional surgical method, including a short hospital stay, usually same-day surgery, minimal risk for complications, and the ability to achieve pain control by using oral analgesics. The nurse is teaching a client with gallbladder disease about diet modification. Which meal would the nurse suggest to the client? A. Sausage and scrambled eggs B. Steak and french fries C. Turkey sandwich on wheat bread D. Fried chicken and mashed potatoes C. Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones. Steak, french fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease. A client is admitted to the emergency department with possible acute pancreatitis. What is the nurse’s priority assessment at this time? A. Respiratory assessment B. Cardiovascular assessment C. Abdominal assessment D. Pain intensity assessment A. Respiratory assessment As for any client, the nurse would want to continually assess for airway, breathing, and circulation. Clients who have acute pancreatitis often develop pleural infusions, atelectasis, or pneumonia. Necrotizing hemorrhagic pancreatitis places the client at risk for acute respiratory distress syndrome (ARDS). A client who had a Whipple surgical procedure develops an internal fistula between the pancreas and stomach. For which complication would the nurse monitor? A. Cirrhosis B. Crohn disease C. Peritonitis D.Peptic ulcer disease C. Peritonitis Leakage of pancreatic enzymes, bile, and/or gastric secretions into the abdomen (peritoneal cavity) often causes peritonitis, which requires IV antibiotic therapy to manage. The nurse is caring for a client who had a Whipple surgical procedure yesterday. For what serum laboratory test results would the nurse want to monitor frequently and carefully? A. Blood glucose B. Blood urea nitrogen C.Phosphorus Platelet count A. Blood glucose During a Whipple procedure, most or all of the pancreas is manipulated, stressed, and possibly removed. Therefore, the client is at risk for hyperglycemia or hypoglycemia and blood glucose would need careful monitoring with a possible need for treatment. A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? A. Assist the client to assume a position of comfort. B. Administer opioid analgesic medication. C. Do not administer food or fluids by mouth. D. Measure intake and output every shift. B. Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority. A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? A. High fat B. High fiber C. Carbohydrates D. Protein D. Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss. Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease. No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with highfat content, and food with high-fiber content. After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? A. Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L). B. Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain. C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Middle-age client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography. C. Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse’s immediate attention. The older adult client’s glucose level will require intervention but, again, is not a medical emergency. The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the client about this medication? A. Wipe your lips after taking pancrelipase. B. Take pancrelipase before meals. C. Administer pancrelipase before taking an antacid. D. Chew tablets before swallowing. A. Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water. A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which nursing actions would the nurse implement to prevent potential complications? (Select all that apply.) A. Ensure that drainage color is clear. B. Check blood glucose often. C. Place the client in the supine position. D. Check bowel sounds and stools. E. Monitor mental status. B, D, E To prevent potential complications after a Whipple procedure, the nurse would check the client’s glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage. Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion. The nurse is reviewing laboratory results of a client recently admitted with a diagnosis of acute pancreatitis. Which values would the nurse expect to be elevated? (Select all that apply.) A. Elastase B. Amylase C. Glucose D. Lipase E. Trypsin F. Calcium A, B, C, D, E The client who has acute pancreatitis experiences elevation of all pancreatic enzymes and glucose. The serum calcium level is usually decreased (rather than elevated) because the release of fatty acids combined with available calcium. What causes stoma ischemia?The stoma first appears edematous with bluish discoloration and then progresses to necrosis. A common cause of ischemia is an inadequate arterial blood supply secondary to damage to or an inappropriately divided vascular arcade supplying the left colon.
How do you know if you have a blockage with a stoma?You will know when you have a blockage as your bag will be empty when usually it is filling up. Another symptom of a blocked stoma, in addition to your output slowing down, is stomach-ache. You may start to feel waves of cramping and abdominal pain, which may worsen if the symptoms you experience are unresolved.
What are 3 common complications of an ostomy?irritation and inflammation of the skin around the stoma. narrowing of the stoma (stoma stricture) a section of the bowel pushing through the opening in the skin (stoma prolapse) an internal part of the body, such as an organ, pushing through a weakness in the muscle or surrounding tissue wall (parastomal hernia)
What does a pale stoma indicate?Major changes in the color of a stoma, including extreme paleness or extremely darkening, are signs that the tissues are not receiving enough blood. An extremely pale stoma means that the blood supply is poor. A purplish, or blackish color is an indication that tissues are dying (referred to as necrosis ).
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The nurse is assessing a newly created colostomy stoma which finding indicates signs of ischemia
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