7MS120 CH 57, 58, & 59 – Flashcards
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What is the pH range of the distal esophagus?
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D -6.0-7.0 -The pH of the lower esophagus is neutral (normal).
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Which is an explanation of conditions that foster esophageal reflux?
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A -Decreased lower esophageal sphincter (LES) tone -Esophageal reflux can occur when the intra-abdominal pressure is elevated or when the sphincter tone of the LES is decreased.
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Which characteristic puts a client at risk for gastroesophageal reflux disease?
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D-Nasogastric tube -A nasogastric tube keeps the cardiac sphincter open, allowing acidic contents from the stomach to enter the esophagus.
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A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication?
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C -Aspiration -Regurgitation of stomach contents while the client is recumbent poses a risk of aspiration for the client.
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Which is the priority assessment of a client experiencing regurgitation?
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A Auscultating lungs for crackles -The client with regurgitation is at risk of aspiration, pneumonia, and bronchitis. The nurse should auscultate the lungs for crackles, an indication of aspiration.
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Which client response to the Bernstein test would confirm the diagnosis of esophagitis?
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B -Heartburn during the test -Clients with esophagitis will experience heartburn as the acidic solution is infused, with a positive Bernstein test result.
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Which is the most accurate method of diagnosing gastroesophageal reflux disease (GERD)?
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C -24-hour ambulatory pH monitoring -The most accurate method of diagnosing gastroesophageal reflux disease is 24-hour ambulatory pH monitoring.
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The nurse should assess for which complication in a client with Barrett's esophagus who is complaining of dysphasia?
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B -Esophageal stricture -In Barrett's esophagus, fibrosis and scarring that accompany the healing process can cause esophageal stricture and lead to difficulty in swallowing.
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Which teaching is a priority for the client with gastroesophageal reflux?
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A -"Eat four to six small meals each day." -The client is instructed to eat four to six small meals daily rather than three larger meals to avoid pressure in the stomach and delayed gastric emptying, which can increase reflux. Evening snacks, carbonated beverages, and acidic foods also should be avoided.
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Which instruction will the nurse give the client to prevent nighttime reflux?
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D -"Elevate the head of the bed 6 to 8 inches for sleep." -Elevation of the head of the bed 6 to 8 inches for sleep is helpful in preventing nighttime reflux episodes related to the recumbent position. Wooden blocks or foam wedges can be used to achieve this level of elevation.
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A client with severe GERD is still having symptoms of reflux despite taking omeprazole, (Prilosec) 20 mg daily. What will the nurse do next?
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B -Obtain an order for omeprazole twice daily. -Omeprazole is a proton pump inhibitor that acts to reduce gastric acid secretion. If once-daily dosing fails to control the client's symptoms, the nurse should obtain an order for the client to take omeprazole twice daily for better symptom control.
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When initiating treatment for GERD with metoclopramide (Reglan), what is essential for the nurse to teach the client?
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C -"This medication can make you feel tired." -Treatment with metoclopramide is associated with neurologic and psychotropic side effects, such as anxiety, fatigue, ataxia, and hallucinations.
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A client who has undergone Nissen fundoplication for GERD is ready for discharge home. Which statement made by the client indicates understanding of the disease?
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D -"I will need to continue to watch my diet and take my medication." -There is a high percentage of recurrence of reflux after this type of surgery, so clients are encouraged to continue antireflux regimens of medication and diet control.
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Which symptom indicates a need for immediate intervention in the client with a rolling hernia?
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D -Obstruction -A rolling hernia causes the fundus and portions of the stomach's greater curvature to roll into the thorax next to the esophagus, predisposing the client to volvulus, obstruction, and strangulation.
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Which statement indicates that the client understands the management of his or her hiatal hernia?
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B -"I will remain upright for several hours after each meal." -Clients with hiatal hernia experience GERD. Positioning is an important intervention. The client should be taught to sleep with the head of the bed elevated, to remain upright after meals for 2 to 3 hours, and to avoid straining or restrictive clothing.
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Which is the first intervention that the nurse will take for the client post-sliding hernia repair to prevent complications?
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B -Elevation of the head of the bed to 30 degrees -The prevention of respiratory complications is the primary focus of postoperative care. The high incision makes taking deep breaths extremely painful for this client. By elevating the head of the bed to at least 30 degrees, the nurse promotes lung expansion in the client.
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A client who has undergone a fundoplication wrap for hernia repair has returned from the postanesthesia care unit with a nasogastric tube draining dark brown fluid. Which is the nurse's priority action?
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B -Documenting the finding and continuing to monitor -After fundoplication, drainage from the nasogastric tube is initially dark brown with old blood. This finding is expected and requires only documentation. The drainage should become yellow-green within 8 hours after surgery.
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Which statement in the client postfundoplication indicates a need for additional dietary teaching?
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A -I should eat three meals a day." -Once the client can tolerate clear fluids, the diet may be advanced. The client should eliminate alcohol, caffeine, and carbonated beverages from the diet. The client should be instructed to eat smaller, more frequent meals because the food storage area of the stomach is reduced by the surgery, and not to eat within 3 hours of bedtime.
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A client who has undergone a fundoplication wrap for hernia repair is preparing for discharge. Which intervention is essential for the nurse to include in discharge instructions?
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C -"Notify your physician if you develop symptoms of a cold." -The client is instructed to report cold or flulike symptoms, because persistent coughing associated with these conditions can cause dehiscence of the incision.
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A client is admitted with progressive dysphagia. Which assessment finding does the nurse expect in this client?
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B -Weight loss -Clients with progressive dysphagia can develop weight loss from the inability to take adequate nutrition.
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A client 2 hours post-esophageal dilation develops chest and shoulder pain. Which is the best action of the nurse?
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D -Further assessing the client for perforation -Chest and shoulder pain may be indicative of bleeding or perforation and require immediate intervention. Administration of an analgesic should not be done until the problem is diagnosed.
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Which factor would place a client at risk for esophageal cancer?
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A 20 pack-year smoking history -In the United States, the two most important factors for the development of esophageal cancer are tobacco use and alcohol ingestion.
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The nurse is performing an assessment of a client with suspected esophageal cancer. Which statement made by the client is indicative of advanced disease?
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D - "I have difficulty swallowing liquids." -Dysphagia does not usually present until the esophageal lumen is 60% occluded. It begins with a sticking sensation in the throat and dysphagia for solids, followed by dysphagia for soft foods. The client with dysphagia for liquids has the most advanced disease.
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Which is the priority intervention in the care of a client with esophageal cancer?
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C -Preventing aspiration -Although nutrition is high on the list of priorities, prevention of aspiration is the highest. When a client aspirates, his or her respiratory system is compromised, thereby causing further deterioration, which increases nutritional needs.
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A client with esophageal cancer and dysphagia states that it has become more difficult to swallow, and the client has experienced several choking episodes during meals. Which strategy would the nurse recommend to assist this client in obtaining adequate nutrition?
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D -Encourage the client to eat semisoft foods and thickened liquids. -The client with dysphagia is usually able to tolerate swallowing semisoft foods and/or thickened liquids to obtain adequate intake. Clear liquids alone may not provide enough calories or nutrients. Efforts are made to preserve swallowing ability as long as possible although, in the case of complete obstruction, a feeding tube may be necessary
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Which finding alerts the nurse to a possible complication in a client with esophageal cancer receiving radiation therapy?
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B -Worsening of dysphagia or odynophagia -Worsening of the client's symptoms may signal the development of monilial esophagitis, a fungal infection that can develop after radiation to the esophagus.
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A client has undergone an esophagogastrostomy for cancer of the esophagus. How will the nurse best support the client's respiratory status?
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D -Administering analgesia regularly -Respiratory care is the highest postoperative priority. Incisional support and adequate analgesia are crucial for effective coughing and deep breathing. As long as vital signs are stable, the nurse administers analgesia regularly to assist the client in performing deep breathing, turning, and coughing routines.
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The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days postesophagogastrostomy. Which is the nurse's priority intervention?
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D -Notifying the physician that the suture line is bleeding -The initial nasogastric drainage appears bloody, but should turn a yellow-green color by the end of the first postoperative day. If the bloody color continues, it may indicate bleeding at the suture line. If the tube is draining, there is no need to irrigate it. Repositioning the tube will not change the drainage.
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Which discharge teaching is essential for the client who is postesophagogastrostomy?
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C -"Drink fluids between, rather than with, meals." -The client is taught to drink fluids between rather than with meals to prevent diarrhea resulting from vagotomy syndrome. The client also should sit upright during and after meals and eat a high-protein diet of six to eight meals daily.
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What will the nurse teach the client with diverticula about dietary needs?
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A -"Eat soft foods and smaller meals." -Soft foods and smaller meals assist in reducing the symptoms of pressure and reflux that accompany diverticula. The client does not have to avoid liquids or dairy products because these do not cause symptoms. The client does not have to eat puréed foods because there is no difficulty swallowing or chewing foods
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A client is admitted with a chemical injury to the esophagus after ingestion of an alkaline substance. The nurse assesses for which potential complication?
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D -Perforation -Although all these complications are possible, ingestion of alkaline substances is dangerous because of their potential to penetrate the esophagus fully, leading to perforation.
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Which is the primary nursing intervention for a client with early esophageal cancer?
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A -Nutritional support -The major concern for a client with esophageal cancer is weight loss secondary to dysphasia. Therefore, nutritional support is required, with intake monitored and weight maintained.
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The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion?
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D -The client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain. -Motrin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastritis, even if symptoms are not yet apparent. Stress, travel, and spicy foods do not increase risk for gastritis.
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The nurse is caring for a female client who has just received a prescription for misoprostol (Cytotec). Which instructions will the nurse provide to the client regarding this medication?
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C -"Make sure that you use an effective form of birth control when you are taking this medication." -Cytotec may cause uterine rupture, miscarriage, and fetal deformities when taken during pregnancy. Clients should be careful not to become pregnant while taking the medication. Cytotec may cause diarrhea and should be taken with food.
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The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse?
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B -Preparing the client for emergency surgery -Sudden, sharp, mid-epigastric pain is indicative of perforation, which is a surgical emergency. Morphine should not be administered, as the surgeon will need to assess the client's abdomen. The client will assume the knee-chest position in an attempt to relieve the pain.
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The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention will the nurse prepare to do for the client?
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C -Insert a nasogastric (NG) tube to low intermittent suction. -Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client should remain NPO and a soap suds cleansing enema is not indicated.
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The home care nurse is caring for a client who has recently undergone a Billroth II operation. The nurse notes that the client's tongue is shiny and beefy red. Which assessment question should the nurse ask the client regarding this finding?
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A -"Have you been taking your multivitamin every day?" -Symptoms of atrophic glossitis are caused by a decrease in vitamin B12, which results from a lack of intrinsic factor secondary to surgical resection of a portion of the stomach. The nurse should check to see if the client has been taking the prescribed multivitamin every day.
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The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed?
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D -"I will take my medication every day until my heartburn is gone." -Long-term medication compliance is crucial to eradicate Helicobacter pylori and prevent recurrence. The nurse stresses the importance of continuing medications for the entire time prescribed.
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The nurse is teaching a health promotion class about preventing cancer. Which statement by a student indicates understanding of gastric cancer development?
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A -"I should skip my morning bacon and egg sandwich to reduce my risk of gastric cancer." -Regular consumption of processed foods with nitrates (including bacon) can increase risk for gastric cancer. Lactose intolerance, coffee intake, and vegetarian diet are not factors for gastric cancer development.
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The nurse is caring for a client with complaints of epigastric pain and nausea. Which assessment finding leads the nurse to conclude that the client's problem is chronic rather than acute?
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D -Macrocytic, normochromic anemia and tachycardia -Pernicious anemia may be seen with chronic gastritis, with macrocytic, normochromic anemia and tachycardia. Low-grade fever, lactose intolerance, hypoalbuminemia, and abdominal bloating do not help differentiate between chronic and acute gastritis.
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The nurse is caring for a client with acute gastritis. The client asks the nurse how to prevent getting gastritis again. Which is the nurse's best response?
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A -"Join a support group to help you stop smoking." -Smoking and stress contribute to the development of gastritis, so the client should join a support group to help him quit smoking. Multivitamins, fiber, and weight management do not help prevent gastritis development.
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The nurse is caring for a male client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than the duodenum?
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A -The client's body mass index (BMI) is 17.6. -A BMI of 17.6 indicates that the client is underweight. This finding is more commonly seen with gastric ulcers than duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than gastric ulcers.
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The nurse is caring for a client who has been brought to the emergency room with upper GI bleeding. The client is unconscious and requires lavage to stop the bleeding. Which is the nurse's priority action?
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A -Preparing to intubate the client with an endotracheal tube -Unconscious clients should be intubated prior to gastric lavage to prevent aspiration of stomach contents into the airway. Large-bore IV lines should be started with 18-gauge angiocatheters. A 14 French nasogastric tube is too small for gastric lavage in an adult client. Continuous suction should be used during gastric lavage.
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The nurse is caring for a client who has just arrived in the emergency room with complaints of epigastric pain. The client reports that an emesis earlier in the day looked like coffee grounds. What will the nurse prepare to do for the client first?
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A -Check the client's stool for occult blood. -IV access should be obtained first to correct hypovolemia and possible transfusion of packed red blood cells. Client history and checking the stool for occult blood can be done later. Gastric lavage is indicated for acute hemorrhage with emesis of bright red blood.
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The nurse is caring for a client who presents with chronic epigastric pain, heartburn, and anorexia. The client asks the nurse how the doctor can best determine if the symptoms are caused by gastritis. Which is the nurse's best response?
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B -"The doctor will take a look inside your stomach using a tube with a light on the end of it." -Endoscopy (esophagogastroduodenoscopy) with biopsy is the best method for diagnosing gastritis. Computed tomography (CT) scans, upper GI series, and blood samples are less accurate for making the diagnosis of gastritis.
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The nurse is caring for a client with congestive heart failure and chronic gastritis. The client tells the nurse that he takes 2 teaspoons of sodium bicarbonate every night before bed to prevent heartburn. Which is the nurse's best response?
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B -"I will let your doctor know so that a safer antacid can be prescribed for you." -Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with congestive heart failure. The physician should be notified right away so that an alternative antacid can be prescribed
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The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts an NG tube for gastric lavage and checks placement of the tube in the stomach. When aspirating fluid from the tube, the pH is found to be 6. Which is the priority action of the nurse?
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A -Obtaining an order for a STAT chest x-ray -A STAT chest x-ray should be obtained whenever there is any doubt as to NG tube placement. The other methods are not appropriate for confirming placement.
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The nurse is caring for a client who has recently undergone a Billroth I procedure. The nurse notes that the client's reflexes are slowed and the client reports tingling in his feet and hands. Which dietary recommendations will the nurse make for this client?
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C -"Eat more shellfish, beef, and salmon." -The client has developed pernicious anemia caused by reduced stomach area and vitamin B12 deficiency. The client should be encouraged to eat foods that are high in vitamin B12, including shellfish, beef, and salmon.
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The nurse is caring for a client with gastritis who will undergo urea breath testing in the morning. Which instructions will the nurse provide for the client?
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C -You may not have anything to eat or drink after midnight tonight." -Urea breath testing requires the client to be NPO after midnight the night before the test. An IV or sedation is not required.
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The nurse is caring for a client who has recently undergone a Billroth II procedure. The client states that whenever he eats, he becomes dizzy and sweaty, with heart palpitations. The client tells the nurse that he is now afraid to eat anything. Which is the nurse's best response?
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D -"You should avoid eating foods that contain large amounts of sugar." -The client's symptoms are consistent with dumping syndrome, which can be minimized by avoiding intake of foods with high sugar content. A clear liquid or lactose-free diet is not appropriate for this client. Clients should avoid drinking fluids with meals to prevent dumping syndrome.
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The nurse is caring for a client who recently has undergone a Billroth II procedure. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse's priority action?
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A -Checking the client's blood sugar level -The client's symptoms are consistent with late dumping syndrome, in which hypoglycemia is caused by increased insulin levels. The client's blood sugar level should be checked immediately.
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The nurse is caring for a client with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The client asks the nurse why he should bother having the surgery because he will not be cured. Which is the nurse's best response?
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B -"The surgery will relieve the obstruction so you will be more comfortable and able to eat again." -Palliative surgery will relieve the gastric outlet obstruction and allow the client to eat again. The surgery will not provide the physicians with an accurate prognosis or prevent metastasis.
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The nurse is caring for a client who will be discharged from the hospital following surgery for advanced gastric cancer. The client's daughter verbalizes the fear that she will not be able to manage her father's symptoms adequately at home. Which is the nurse's best response?
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C -"I will ask the social worker to arrange for a hospice nurse to help you care for your father at home." -Hospice nurses can assist family members with caring for clients who are terminally ill. The nurse should not belittle the daughter's concerns or ask the physician to review the discharge instructions again.
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The nurse is caring for a client who reports persistent epigastric pain, heartburn, and nausea, despite faithfully taking ranitidine (Zantac), aluminum hydroxide (Amphojel), and metronidazole (Flagyl) as prescribed. Which is the nurse's best response?
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D -"Have you been experiencing foul-smelling diarrhea lately?" -Peptic ulcer disease (PUD) symptoms that are not alleviated by medications may indicate Zollinger-Ellison syndrome, a similar condition that is often refractory to treatment. A hallmark of Zollinger-Ellison syndrome is diarrhea and steatorrhea, with frothy, foul-smelling diarrhea.
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A client with Zollinger-Ellison syndrome will be admitted to the medical unit. Which intervention will the nurse include in the client's nursing plan of care?
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B -Performing perineal care with warm water and applying a moisture barrier twice daily -Clients with Zollinger-Ellison syndrome often experience severe diarrhea and steatorrhea, so the nurse should include careful perineal care in the plan of care. Abdominal fluid wave testing and shifting dullness checks for ascites, which is not seen with Zollinger-Ellison syndrome. The client's physician is responsible for ordering transfusion of blood, not the nurse.
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The nurse is caring for a client who takes magnesium hydroxide with aluminum hydroxide (Maalox) at home to control epigastric pain. Which finding from the client's health history leads the nurse to recommend taking aluminum hydroxide (Amphojel) instead?
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C -The client has a history of chronic kidney disease. -Poor renal perfusion caused by heart failure can cause retention of magnesium by the kidneys, leading to toxicity. Maalox can be taken safely with Prilosec and aspirin. Chronic constipation does not contraindicate the use of Maalox.
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The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurse's best response?
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A -"Zantac will help prevent the development of a stomach ulcer from the stress of your injuries." -Clients who have sustained traumatic injuries are at risk for development of stress ulcers during recovery. H2 antagonist medications may be prescribed to prevent stress ulcers. Zantac will not prevent aspiration pneumonia, esophageal healing after nasogastric intubation, or nausea from narcotic pain medications.
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The nurse is to insert a nasogastric tube for a client with upper GI bleeding. Which instructions will the nurse give to the client before starting the procedure?
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A -"You may take some sips of water when I begin to insert the tube into your nose." -Tilting the head down toward the chest after the NG tube has reached the back of the throat will facilitate intubation of the esophagus rather than the trachea. The client should be encouraged to mouth-breathe and swallow during the procedure. The tube should be measured from the nose to the earlobe to the umbilicus. Sips of water should be encouraged once the tube is at the back of the throat, not at the beginning of the procedure.
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Which menu selections by the client with irritable bowel syndrome indicates that teaching was understood?
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B -Broiled chicken with brown rice, tossed green salad, glass of apple juice -Clients with irritable bowel syndrome are advised to eat a high-fiber diet, with 8 to 10 cups of liquid daily. They should avoid alcohol, caffeine, and other gastric irritants.
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Which assessment finding leads the nurse to check the client's abdomen for an acquired umbilical hernia?
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A -The client's body mass index (BMI) is 41.9. -This type of hernia is associated with obesity. The other assessment findings do not place the client at increased risk for an acquired umbilical hernia.
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The nurse notes a bulge in the client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings?
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A -The client has a reducible inguinal hernia. -In a reducible hernia, the contents of the hernial sac can be replaced into the abdominal cavity by gentle pressure or by lying flat. The contents of irreducible, strangulated, or incarcerated hernias may not be replaced into the abdomen when the client lies down. An umbilical hernia is not located in the groin area but at the client's navel.
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The nurse is caring for a client with an umbilical hernia who complains of abdominal pain, nausea, and vomiting. The nurse notes hypoactive, high-pitched bowel sounds. Which conclusion does the nurse draw from these assessment findings?
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A -The client has developed a bowel obstruction. -The client with a hernia presenting with abdominal pain, fever, tachycardia, nausea and vomiting, and hypoactive bowel sounds should be suspected of having developed strangulation. Strangulation poses a risk of intestinal obstruction. The symptoms are not suggestive of enlargement of the hernia, adhesion formation, or bowel perforation.
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The nurse is teaching the client how to use a truss for a femoral hernia. Which statement by the client indicates the need for further teaching?
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B -"I will wear the truss over a T shirt to avoid skin irritation." -The truss should be worn against the skin, not over the T shirt or underwear. The client is instructed to apply the truss before arising, not before going to bed at night. The truss should be cleaned with a damp cloth a few times a week. The physician should be notified immediately if abdominal pain develops, because the hernia may have become strangulated or incarcerated.
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The nurse is providing preoperative teaching for a client who will have herniorrhaphy surgery. Which instructions will the nurse give to the client?
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B -"Change the dressing every day until the staples are removed." -The dressing should be changed every day until the staples are removed so that the client can check the incision for signs of infection. Constipation is common following hernia surgery, so clients should include adequate amounts of fiber in the diet. The maximum daily dosage of Tylenol is 4000 mg. Taking 1000 mg of Tylenol every 4 hours would be 6000 mg/day, which could cause toxicity and liver damage. The client should change positions and take deep breaths to facilitate lung expansion, but should avoid coughing, which can place stress on the incision line
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The nurse is performing a physical assessment for a client who underwent bowel resection surgery the previous day. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which is the nurse's priority action?
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B -Determining the last time that the client voided -The assessment findings indicate that the client may have an overfull bladder. In the immediate postoperative period, the client may experience difficulty voiding. The nurse should take care not to allow the bladder to become distended, because it places stress on the incision line. A rectal tube should not be inserted for a client who had a bowel resection the previous day. The client's vital signs may be checked after the nurse determines the client's last void.
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The nurse is screening clients at a community health fair. Which client is at the highest risk for the development of colorectal cancer?
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D -An older man who travels extensively and eats fast food frequently -Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Irritable bowel syndrome, a heavy workload, and coffee intake do not increase the risk for colon cancer. A BMI of 19.2 is within normal limits.
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The nurse is performing a physical assessment of a client with a new diagnosis of colorectal cancer. The nurse notes the presence of visible peristaltic waves and, on auscultation, hears high-pitched bowel sounds. Which conclusion does the nurse draw from these findings?
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C -The client's growing tumor has caused a partial bowel obstruction. -The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, are indicative of a partial obstruction from the tumor. The assessment findings do not indicate metastasis to the liver, intussusception of the intestine, or toxic megacolon.
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The nurse is caring for a client who is scheduled to have fecal occult blood testing. Which instructions will the nurse give to the client?
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C -"You will need to avoid eating meat for 48 hours before the test." - The client is instructed to avoid foods such as meats, horseradish, and beets, which may give a false-positive result to the test. The other instructions are not appropriate for fecal occult blood testing.
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A client who has had fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day. Which is the nurse's best response?
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C -"This does not rule out the possibility of colon cancer." -A negative result does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so that the entire colon can be visualized and a tissue sample taken for biopsy. The client need not wait a week before the colonoscopy. Two negative fecal occult blood tests do not rule out the presence of colorectal cancer.
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The nurse is caring for a client who has been newly diagnosed with colon cancer. The client has become withdrawn from family members. Which strategy will the nurse use to assist the client at this time?
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C -Encouraging the client to verbalize feelings about the diagnosis -The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the client's feelings with a generalization about cancer prognosis and treatment. The nurse should not ignore the client's withdrawal behavior.
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The nurse is caring for a client with colon cancer and a new colostomy. The client wishes to talk with someone with a similar experience. Which is the nurse's best response?
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B -"I will make a referral to the local chapter of the American Cancer Society." -Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the American Cancer Society has resources for clients and their families. Although the enterostomal therapist is an expert in ostomy care, it is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that there are no colostomy clients on the unit at the time.
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Nurses need to become familiar with community-based resources to assist clients better. The local chapter of the American Cancer Society has resources for clients and their families. Although the enterostomal therapist is an expert in ostomy care, it is not the same as talking with someone who actually has had a colostomy. Many people are willing to share their ostomy experience in the hope of helping others. The nurse should not brush aside the client's request by saying that there are no colostomy clients on the unit at the time.
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D -Serum transaminase, 129 IU/L -The level of serum transaminase, a liver enzyme, is elevated with liver trauma. The other laboratory values are within normal limits and are not specific for the liver.
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The nurse is caring for a client who is brought to the emergency department following a motor vehicle crash. The nurse notes that the client has ecchymotic areas across the lower abdomen. Which is the priority action of the nurse?
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B -Assessing for abdominal guarding or rigidity -On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, which could indicate peritoneal irritation from internal bleeding. Measuring abdominal girth or asking about seating in the car is not appropriate. Checking laboratory test results can be done after assessing for abdominal guarding or rigidity.
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The client tells the nurse that her husband is repulsed by her colostomy and refuses to be intimate with her after surgery. Which is the nurse's best response?
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A -"Let's talk to the ostomy nurse to help you and your husband work through this." -The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not try to minimize the client's concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by becoming intimate with her husband.
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The nurse is caring for a client who just had colon resection surgery with a new colostomy. Which teaching objective will the nurse include in the client's plan of care?
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C - The client will demonstrate correct changing of the appliance before discharge. -Client learning goals must be measurable so that the nurse can determine whether they have been met. When the goal is to have the client demonstrate a particular skill, the nurse can easily determine whether the goal was met. The other goals are all subjective and cannot be measured objectively.
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The nurse is caring for a client who has been diagnosed with a bowel obstruction. Which assessment finding leads the nurse to conclude that the obstruction is in the small bowel?
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A -The client's potassium is 2.8 mEq/L, with a sodium value of 121 mEq/L. -Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range, 3.5 to 5.0 mEq/L) and hyponatremic (normal range, 136 to 145 mEq/L). Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer and consequent large bowel obstruction. High-pitched, hyperactive bowel sounds may be noted with large and small bowel obstructions. Crampy abdominal pain across the lower quadrants is associated with large bowel obstruction
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The nurse is caring for a female client who is chronically anemic following gastric bypass surgery. The client asks the nurse why this is happening. Which is the nurse's best response?
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C -"You have less small bowel, so essential nutrients for red blood cell formation are not being absorbed." -During gastric bypass surgery, a large amount of the stomach and small intestine is bypassed in order to facilitate rapid weight loss. This causes malabsorption of nutrients necessary for red blood cell formation, including folic acid, vitamin B12, and iron. The other responses are not appropriate
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The nurse is planning discharge teaching for a client who has developed a bowel obstruction from fecal impaction. Which instructions will the nurse provide to the client?
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A -"Take fiber supplements every day with at least 16 ounces of water." -Castor oil should be avoided long-term because it can be aspirated into the lungs or interfere with the absorption of fat-soluble vitamins. Amphojel can cause constipation. Carbonated drinks do not cause or relieve constipation. Fiber supplements may be taken daily to prevent constipation and should be taken with at least 16 ounces of water to prevent esophageal obstruction.
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A client with a mechanical bowel obstruction reports that the abdominal pain that was previously intermittent and colicky is now more constant. Which is the priority action of the nurse?
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D -Checking the abdomen for bowel sounds and rebound tenderness -A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse need not measure the abdominal girth. The nurse may help the client to the knee-chest position for comfort, but it is not the priority action. The nurse should not medicate the client until the physician has been notified of the change in his or her condition.
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The nurse is caring for a client who has just had hemorrhoid surgery. Which nursing intervention will the nurse include in the plan of care for the client?
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D -Having the client clean the rectal area with moist witch hazel wipes after defecation -The rectal area should be cleaned with moist witch hazel wipes after defecation to reduce pain and irritation. The client is encouraged to soak in a warm bath, but chamomile should not be added. The client should not spend extended periods of time sitting on the toilet, because this can increase rectal pressure and worsen hemorrhoids.
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The nurse is caring for a client who is to receive 5-fluorouracil (5-FU) chemotherapy IV for the treatment of colon cancer. Which assessment finding leads the nurse to contact the physician and reschedule the infusion for another day?
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A -The client's white blood cell count is 3500/mm3. -5-FU can cause leukopenia, and the client's white blood cell count is already significantly low (normal range, 5,000 to 10,000/mm3). The chemotherapy should be deferred until the client's white blood count is above 3,500/mm3. The other assessment findings are consistent with common side effects of 5-FU that would not delay administration of the next dose.
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A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response?
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A -"This is normal for your type of colostomy." -The stool from an ascending colostomy can be expected to remain liquid because there is little large bowel to reabsorb the liquid from the stool. The physician may be notified, but this is not the best response from the nurse. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the client's diet.
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Which instructions will the nurse provide to the client who has just been prescribed oxaliplatin (Eloxatin) for the treatment of colon cancer?
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B -"Wear gloves whenever you get food out of the freezer." -Eloxatin can cause peripheral neuropathy that is triggered by exposure to the cold. The client should wear gloves whenever her or his hands are exposed to cold temperatures, even for short periods. The other instructions are not appropriate for Eloxatin.
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The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response?
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A -"You are at risk for developing more polyps in the future." -Once a person has developed a polyp, there is a risk of multiple polyps occurring. The physician can usually remove all visible polyps during the colonoscopy procedure. Follow-up colonoscopy is not done to ensure that healing occurred where a polyp was removed or to check for cancerous lesions that were not visible during the first procedure.
