The nurse is monitoring a client admitted to the hospital with a
diagnosis of appendicitis who is scheduled for
surgery in 2 hours. The client begins to complain of increased
abdominal pain and begins to vomit. On
assessment, the nurse notes that
the abdomen is
distended and bowel sounds are
diminished. Which is the most appropriate
nursing
intervention?
1. Notify the surgeon.
2.
Administer the prescribed pain medication.
3. Call and ask the
operating room team to perform
surgery as soon as
possible.
4. Reposition the client and apply a heating pad
on
the warm setting to the client’s abdomen.
1. Notify the surgeon
Rationale: On the basis of the signs and symptoms
presented
in the question, the nurse would suspect
peritonitis and notify
the surgeon.
Administering pain medication is not an appropriate intervention.
Heat would never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture.
Scheduling surgical time is not within the scope of
nursing
practice, although the surgeon probably would perform the surgery
earlier than the prescheduled time.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.
1. Diarrhea
2. Black, tarry stools
3. Hyperactive bowel
sounds
4. Gray-blue color at the ank
5. Abdominal
guarding and tenderness
6. Left upper quadrant pain with
radiation to the
back
4. Gray-blue color at the flank - Turner's sign
5. Abdominal guarding and tenderness
6. Left upper
quadrant pain with radiation to the back
Rationale: Grayish-blue discoloration at the
flank is known as Turner’s sign and occurs as a result of
pancreatic enzyme
leakage
to cutaneous tissue from the peritoneal cavity.
The client may demonstrate abdominal guarding and may complain of tenderness with palpation.
The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect
The nurse is assessing a client who is experiencing an acute
episode of cholecystitis. Which of these clinical
manifestations support this diagnosis?
Select all that
apply.
1. Fever
2. Positive Cullen’s sign
3.
Complaints of indigestion
4. Palpable mass in the left upper
quadrant
5. Pain in the upper right quadrant after a
fatty
meal
6. Vague lower right quadrant abdominal discomfort
1. Fever
3. Complaints of indigestion
5. Pain in the
upper right quadrant after a fatty meal
Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal.
Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting.
Options 4 and 6 are incorrect because they are
inconsistent
with the anatomical location of the gallbladder.
Option 2
(Cullen’s sign) is associated with pancreatitis.
A client diagnosed with viral hepatitis is complaining of “no
appetite” and “losing my taste for food.”
What instruction would
the nurse give the client to
provide adequate nutrition?
1.
Select foods high in fat.
2. Increase intake of fluids, including
juices.
3. Eat a good supper, when anorexia is less
severe.
4. Eat less often, preferably only three large meals
daily.
2. Increase intake of fluids, including juices.
Rationale: Although no special diet is required to
treat viral
hepatitis, it is generally recommended that clients
consume
a low-fat diet, as fat may be tolerated poorly because
of
decreased bile production.
Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important
A client has developed hepatitis A after eating contaminated oysters.
The nurse assesses the client for
which expected assessment
finding?
1. Malaise
2. Dark stools
3. Weight
gain
4. Left upper quadrant discomfort
1. Malaise
Rationale: Hepatitis causes gastrointestinal symptoms
such
as anorexia, nausea, right upper quadrant
discomfort, and
weight loss.
Fatigue and malaise are common.
Stools will be
light- or clay-colored if
conjugated bilirubin is unable to flow
out of the liver because
of inflammation or obstruction of the
bile ducts.
A client has just had a hemorrhoidectomy. Which
nursing
interventions are appropriate for this client?
Select all that
apply.
1. Administer stool softeners as prescribed.
2.
Instruct the client to limit fluid intake to avoid
urinary
retention.
3. Encourage a high-ber diet to promote
bowel
movements without straining.
4. Apply cold packs to
the anal-rectal area over the
dressing until the packing is
removed.
5. Help the client to a Fowler’s position to
place
pressure on the rectal area and decrease bleeding
1. Administer stool softeners as prescribed.
3. Encourage a
high-fiber diet to promote bowel movements without straining.
4.
Apply cold packs to the anal-rectal area over the dressing until the
packing is removed.
Rationale: Nursing
interventions after a hemorrhoidectomy
are aimed at management
of pain and avoidance of bleeding
and incision rupture. Stool
softeners and a high-fiber diet will
help the client avoid
straining, thereby reducing the chances
of rupturing the
incision. An ice pack will increase comfort
and decrease
bleeding. Options 2 and 5 are incorrect interventions.
The nurse is planning to teach a client with gastroesophageal reflux
disease (GERD) about substances
to avoid. Which items would the
nurse include on
this list? Select all that apply.
1.
Coffee
2. Chocolate
3. Peppermint
4. Nonfat
milk
5. Fried chicken
6. Scrambled eggs
1. Coffee
2. Chocolate
3. Peppermint
5. Fried
chicken
Rationale: Foods that decrease lower
esophageal sphincter
(LES) pressure and irritate the esophagus
will increase reflux
and exacerbate the symptoms of GERD and
therefore need to
be avoided. Aggravating substances include
coffee, chocolate,
peppermint, fried or fatty foods, carbonated
beverages, and
alcohol. Options 4 and 6 do not promote this effect
A client suspected of having a duodenal ulcer has
undergone
esophagogastroduodenoscopy. The nurse
would place highest
priority on which item as part
of the client’s care plan?
1.
Monitoring the temperature
2. Monitoring complaints of
heartburn
3. Giving warm gargles for a sore throat
4.
Assessing for the return of the gag reflex
4. Assessing for the return of the gag reflex
Rationale: The nurse places highest priority on
assessing for
return of the gag reflex. This assessment addresses
the client’s
airway. The nurse also monitors the client’s vital
signs and for
a sudden increase in temperature, which could
indicate perforation of the gastrointestinal tract. This complication
would be
accompanied by other signs as well, such as pain.
Monitoring
for sore throat and heartburn are also important;
however, the
client’s airway is the priority.
The nurse has taught the client with suspected gallbladder disease
about an upcoming endoscopic retrograde cholangiopancreatography
(ERCP) procedure. The nurse determines that the client needs further
information if the client makes which statement?
1. “I know I
must sign the consent form.”
2. “I hope the throat spray keeps me
from gagging.”
3. “I’m glad I don’t have to lie still for this
procedure.”
4. “I’m glad some intravenous medication will
be
given to relax me.”
3. “I’m glad I don’t have to lie still for this procedure.”
Rationale: The client does have to lie still for
ERCP, which
takes about 1 hour to perform. The client also has to
sign a
consent form. Intravenous sedation is given to relax the
client,
and an anesthetic spray is used to help keep the client
from
gagging as the endoscope is passed.
The primary health care provider has determined
that a client
has contracted hepatitis A based on
flulike symptoms and
jaundice. Which statement
made by the client supports this
medical diagnosis?
1. “I have had unprotected sex with multiple
partners.”
2. “I ate shellfish about 2 weeks ago at a local
restaurant.”
3. “I was an intravenous drug abuser in the past
and
shared needles.”
4. “I had a blood transfusion 30 years
ago after major abdominal surgery.”
2. “I ate shellfish about 2 weeks ago at a local restaurant.”
Rationale: Hepatitis A is transmitted by the fecal-oral route
via
contaminated water or food (improperly cooked shellfish),
or
infected food handlers. Hepatitis B, C, and D are
transmitted
most commonly via infected blood or body fluids, such
as in
the cases of intravenous drug abuse, history of blood
transfusion, or unprotected sex with multiple partners
The nurse is assessing a client 24 hours after a cholecystectomy. The
nurse notes that the T-tube has
drained 750 mL of green-brown
drainage since the
surgery. Which nursing intervention is most
appropriate?
1. Clamp the T-tube.
2. Irrigate the
T-tube.
3. Notify the surgeon.
4. Document the finding
4. Document the finding
Rationale: Following
cholecystectomy, drainage from the
T-tube is initially bloody
and then turns a greenish-brown
color. The drainage is measured
as output. The amount of
expected drainage will range from 500
to 1000 mL/day. The
nurse would document the output.
The nurse is monitoring a client with a diagnosis of
peptic
ulcer. Which assessment finding would most
likely indicate
perforation of the ulcer?
1. Bradycardia
2. Numbness in the
legs
3. Nausea and vomiting
4. A rigid, boardlike abdomen
4. A rigid, boardlike abdomen
Rationale: Perforation of an ulcer is a surgical
emergency and is
characterized by sudden, sharp, intolerably
severe pain beginning in the midepigastric area and spreading over the
abdomen, which becomes rigid and boardlike. Nausea and vomiting may
occur. Tachycardia may occur as hypovolemic shock
develops.
Numbness in the legs is not an associated finding.
A client with severe ulcer disease in the distal stomach undergoes a
gastrojejunostomy (Billroth II procedure). Which postoperative
prescription would
the nurse question and verify?
1. Leg
exercises
2. Early ambulation
3. Irrigating the nasogastric
tube
4. Coughing and deep-breathing exercise
3. Irrigating the nasogastric tube
Rationale: In a gastrojejunostomy (Billroth II
procedure),
the proximal remnant of the stomach is anastomosed to
the
proximal jejunum. Patency of the nasogastric tube is
critical
for preventing the retention of gastric secretions. The
nurse
would never irrigate or reposition the gastric tube after
gastric
surgery, unless specifically prescribed by the primary
health
care provider. In this situation, the nurse needs to
clarify the
prescription. Options 1, 2, and 4 are appropriate
postoperative interventions
The nurse is providing discharge instructions to a
client
following gastrectomy and would instruct the
client to take which
measure to assist in preventing
dumping syndrome?
1.
Ambulate following a meal.
2. Limit the fluids taken with
meals.
3. Eat cakes and pastries only if they are
homemade.
4. Eat three meals a day rather than small frequent
meals
2. Limit the fluids taken with meals.
Rationale: Dumping syndrome is a term that refers to
a constellation of vasomotor symptoms that occurs after eating,
especially following a gastrojejunostomy (Billroth II
procedure).
Early manifestations usually occur within 30 minutes
of eating and include vertigo, tachycardia, syncope, sweating, pallor,
palpitations, and the desire to lie down. The nurse
would
instruct the client to decrease the amount of fluid taken
at
meals. Complex carbohydrate foods such as oatmeal and
other
whole-grain foods high in fiber will help to prevent
dumping
syndrome but high sugar foods, such as candy, table
sugar,
syrup, sodas and juices, cakes, and pastries need to be
avoided
whether they are homemade or store bought. The client
needs
to lie down for 15 to 30 minutes after eating to delay
gastric
emptying; ambulation will cause rapid gastric emptyin
The nurse is reviewing the prescription for a client
admitted to
the hospital with a diagnosis of acute
pancreatitis. Which
interventions would the nurse
expect to be prescribed for the
client? Select all that
apply.
1. Maintain NPO (nothing by
mouth) status.
2. Encourage coughing and deep breathing.
3. Give small, frequent high-calorie feedings.
4. Maintain the
client in a supine and at position.
5. Give hydromorphone
intravenously as prescribed for pain.
6. Maintain intravenous
uids at 10 mL/hr to
keep the vein open.
1. Maintain NPO (nothing by mouth) status.
2. Encourage
coughing and deep breathing.
5. Give hydromorphone intravenously
as prescribed for pain.
Rationale: The client with acute pancreatitis
normally is
placed on NPO status to rest the pancreas and
suppress gastrointestinal secretions, so adequate intravenous
hydration is
necessary. Because abdominal pain is a prominent
symptom
of pancreatitis, pain medications such as hydromorphone
are
prescribed. Some clients experience lessened pain by assuming
positions that flex the trunk, with the knees drawn up
to the
chest. A side-lying position with the head elevated 45
degrees
decreases tension on the abdomen and may help
ease the pain. The
client is susceptible to respiratory infections because the
retroperitoneal fluid raises the diaphragm,
which causes the
client to take shallow, guarded abdominal
breaths. Therefore,
measures such as turning, coughing, and
deep breathing are instituted.
The nurse is providing discharge teaching for
a client with
newly diagnosed Crohn’s disease
about dietary measures to
implement during exacerbation episodes. Which statement made
by
the client indicates a need for further instruction?
1.
“I need to increase the fiber in my diet.”
2. “I will need to
avoid caffeinated beverages.”
3. “I’m going to learn some
stress-reduction techniques.”
4. “I can have exacerbations and
remissions with
Crohn’s disease.”
1. “I need to increase the fiber in my diet.”
Rationale: Crohn’s disease is an inflammatory disease
that
can occur anywhere in the gastrointestinal tract but most
often
affects the terminal ileum and leads to thickening and
scarring, a narrowed lumen, fistulas, ulcerations, and
abscesses.
It is characterized by exacerbations and remissions.
If stress
increases the symptoms of the disease, the client is
taught
stress-management techniques and may require
additional
counseling. The client is taught to avoid
gastrointestinal stimulants containing caffeine and to follow a
high-calorie and
high-protein diet. A low-fiber diet may be
prescribed, especially during periods of exacerbation.
The nurse is reviewing the record of a client with a
diagnosis
of cirrhosis and notes that there is documentation of the presence of
asterixis. How would
the nurse assess for its presence?
1.
Dorsiex the client’s foot.
2. Measure the abdominal
girth.
3. Ask the client to extend the arms.
4. Instruct the
client to lean forward.
3. Ask the client to extend the arms.
Rationale: Asterixis is irregular flapping movements
of the
fingers and wrists when the hands and arms are
outstretched,
with the palms down, wrists bent up, and fingers
spread.
Asterixis is the most common and reliable sign that
hepatic
encephalopathy is developing. Options 1, 2, and 4 are incorrect.
The nurse is reviewing the laboratory results for a client with
cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L).
Which dietary selection does the nurse suggest to
the
client?
1. Roast pork
2. Cheese omelet
3.
Pasta with sauce
4. Tuna fish sandwich
3. Pasta with sauce
Rationale: Cirrhosis is a chronic, progressive
disease of the
liver characterized by diffuse degeneration and
destruction of
hepatocytes. The serum ammonia level assesses the
ability of
the liver to deaminate protein byproducts. Normal
reference
interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of
the
ammonia in the body is found in the gastrointestinal
tract.
Protein provided by the diet is transported to the liver
by the
portal vein. The liver breaks down protein, which results
in
the formation of ammonia. Foods high in protein would
be
avoided since the client’s ammonia level is elevated above
the
normal range; therefore, pasta with sauce would be the best
selection.
Focus on the subject, an ammonia level
of 85 mcg/dL (51
mcmol/L). Realizing that this result is above
the normal range
will direct you away from selecting highprotein foods, such as pork,
cheese, eggs, and fish
The nurse is doing an admission assessment on a
client with a
history of duodenal ulcer. To determine whether the problem is
currently active, the
nurse would assess the client for which
manifestation of duodenal ulcer?
1. Weight loss
2. Nausea
and vomiting
3. Pain relieved by food intake
4. Pain
radiating down the right arm
3. Pain relieved by food intake
Rationale: A frequent symptom of duodenal ulcer is
pain that
is relieved by food intake. These clients generally
describe the
pain as a burning, heavy, sharp, or “hungry” pain
that often
localizes in the midepigastric area. The client with
duodenal
ulcer usually does not experience weight loss or nausea
and
vomiting. These symptoms are more typical in the client
with
a gastric ulcer.
A client with hiatal hernia chronically experiences
heartburn
following meals. The nurse would plan
to teach the client to
avoid which action because it
is contraindicated with a hiatal
hernia?
1. Lying recumbent following meals
2. Consuming
small, frequent bland meals
3. Taking H2-receptor antagonist
medication
4. Raising the head of the bed on 6-inch (15 cm) blocks
1. Lying recumbent following meals
Rationale: Hiatal hernia is caused by a protrusion of
a portion of the stomach above the diaphragm where the esophagus
usually is positioned. The client usually experiences pain
from
reflux caused by ingestion of irritating foods, lying
flat
following meals or at night, and eating large or fatty
meals.
Relief is obtained with the intake of small, frequent,
and bland
meals; use of H2
-receptor antagonists and antacids; and
elevation of the thorax following meals and during
sleep.
The nurse is providing care for a client with a
bowel
obstruction who had a transverse colostomy created. Which
observation requires immediate notication of the primary health care
provider?
1. Stoma is beefy red and shiny
2. Purple
discoloration of the stoma
3. Skin excoriation around the
stoma
4. Semiformed stool noted in the ostomy pouch
2. Purple discoloration of the stoma
Rationale: Ischemia of the stoma would be associated
with a
dusky or bluish or purple color. A beefy red and shiny
stoma
is normal and expected. Skin excoriation does need to
be
addressed and treated, but immediate attention is required
for
purple discoloration of the stoma. Semiformed stool is a
normal finding.
A client had a new colostomy created 2 days earlier
and is
beginning to pass malodorous flatus from the
stoma. What is the
correct interpretation by the nurse?
1. This is a normal,
expected event.
2. The client is experiencing early signs of
ischemic
bowel.
3. The client should not have the
nasogastric tube
removed.
4. This indicates inadequate
preoperative bowel
preparation.
1. This is a normal, expected event.
Rationale: As peristalsis returns following creation
of a
colostomy, the client begins to pass malodorous flatus.
This
indicates returning bowel function and is an expected
event.
Within 72 hours of surgery, the client would begin
passing
stool via the colostomy. Options 2, 3, and 4 are incorrect
interpretations
A client with severe Crohn’s disease has just had surgery to create
an ileostomy. The nurse assesses the client in the immediate
postoperative period for which
most frequent complication of this
type of surgery?
1. Folate deficiency
2. Malabsorption of
fat
3. Intestinal obstruction
4. Fluid and electrolyte imbalance
4. Fluid and electrolyte imbalance
Rationale:
A frequent complication that occurs following ileostomy is fluid and
electrolyte imbalance. The client requires constant monitoring of
intake and output to prevent this from occurring. Losses require
replacement by intravenous infusion until the
client can
tolerate a diet orally. Intestinal obstruction is a less frequent
complication. Fat malabsorption and folate deficiency
are
complications that could occur later in the postoperative period.
The nurse provides instructions to a client about
measures to
treat irritable bowel syndrome (IBS).
Which statement by the
client indicates a need for
further teaching?
1. “I need to
limit my intake of dietary fiber.”
2. “I need to drink plenty, at
least 8 to 10 cups daily.”
3. “I need to eat regular meals and
chew my food well.”
4. “I will take the prescribed medications
because
they will regulate my bowel patterns.”
1. “I need to limit my intake of dietary fiber.”
Rationale: IBS is a functional gastrointestinal
disorder that
causes chronic or recurrent diarrhea, constipation,
and/or
abdominal pain and bloating. Dietary fiber and bulk
help
produce bulky, soft stools and establish regular bowel
elimination habits. Therefore, the client would consume a highfiber
diet. Eating regular meals, drinking 8 to 10 cups of liquid
a
day, and chewing food slowly help promote normal bowel
function.
Medication therapy depends on the main symptoms
of IBS.
Bulk-forming laxatives or antidiarrheal agents or other
agents
may be prescribed.
The nurse is monitoring a client for the early signs
and
symptoms of dumping syndrome. Which findings indicate this
occurrence?
1. Sweating and pallor
2. Bradycardia and
indigestion
3. Double vision and chest pain
4. Abdominal
cramping and pain
1. Sweating and pallor
Rationale: Early
manifestations of dumping syndrome occur
5 to 30 minutes after
eating. Symptoms include vertigo, tachycardia, syncope, sweating,
pallor, palpitations, and the desire
to lie down
The nurse has given instructions to a client with biliary disease who
has just been prescribed cholestyramine. Which statement by the client
indicates a
need for further instruction?
1. “I will
continue to take vitamin supplements.”
2. “This medication will
help lower my cholesterol.”
3. “This medication would only be
taken with water.”
4. “A high-fiber diet is important while
taking this
medication.”
3. “This medication would only be taken with water.”
Rationale: Cholestyramine is a bile acid sequestrant
used to
lower the cholesterol level, and treat biliary
obstruction and
pruritus associated with biliary disease. Client
adherence to
the medication regimen is a problem because of its
taste and
palatability. The use of flavored products or fruit
juices can
improve the taste. Some side effects of bile acid
sequestrants
include constipation and decreased vitamin absorptio
11. The nurse determines that the client needs
further
instruction on cimetidine if which statements
were
made? Select all that apply.
1. “I will take the
cimetidine with my meals.”
2. “I’ll know the medication is
working if my diarrhea stops.”
3. “My episodes of heartburn will
decrease if the
medication is effective.”
4. “Taking the
cimetidine with an antacid will increase its effectiveness.”
5.
“I will notify my doctor if I become depressed
or anxious.”
6. “Some of my blood levels will need to be monitored closely since I
also take warfarin for atrial
brillation.
1. “I will take the cimetidine with my meals.”
2. “I’ll know
the medication is working if my diarrhea stops.”
4. “Taking the
cimetidine with an antacid will increase its effectiveness.”
Rationale: Cimetidine, a histamine (H2)-receptor
antagonist, helps alleviate the symptom of heartburn, not
diarrhea.
Because cimetidine crosses the blood–brain barrier,
central
nervous system side and adverse effects, such as mental
confusion, agitation, depression, and anxiety, can occur.
Food
reduces the rate of absorption, so if cimetidine is taken
with
meals, absorption will be slowed. Antacids decrease
the
absorption of cimetidine and need to be taken at least 1
hour
apart. If cimetidine is concomitantly administered with
warfarin therapy, warfarin doses may need to be reduced, so
prothrombin and international normalized ratio results must be
followed.
A client with gastroesophageal reflux disease has a
new
prescription for metoclopramide. On review of
the chart, the
nurse identifies that this medication
can be safely administered
with which condition?
1. Intestinal obstruction
2. Peptic
ulcer with melena
3. Diverticulitis with perforation
4.
Vomiting following cancer chemotherapy
4. Vomiting following cancer chemotherapy
Rationale: Metoclopramide is a gastrointestinal
stimulant
and antiemetic. Because it is a gastrointestinal
stimulant, it
is contraindicated with gastrointestinal
obstruction, hemorrhage, or perforation. It is used in the treatment
of vomiting
after surgery, chemotherapy, or radiation.
A client with a peptic ulcer is diagnosed with a Helicobacter pylori
infection. The nurse is teaching the client about the medications
prescribed, including clarithromycin, esomeprazole, and
amoxicillin.
Which statement by the client indicates the best
understanding of the medication regimen?
1. “My ulcer will heal
because these medications
will kill the bacteria.”
2. “These
medications are taken only when I have
pain from my
ulcer.”
3. “The medications will kill the bacteria and
stop
the acid production.”
4. “These medications will coat
the ulcer and decrease the acid production in my stomach.”
3. “The medications will kill the bacteria and stop the acid production.”
Rationale: Triple therapy for H. pylori infection
usually
includes two antibacterial medications and a proton
pump
inhibitor. Clarithromycin and amoxicillin are
antibacterials.
Esomeprazole is a proton pump inhibitor. These
medications
will kill the bacteria and decrease acid production.
8. A client with peptic ulcer disease has been taking
omeprazole
for 4 weeks. The ambulatory care nurse
evaluates that the client
is receiving the optimal intended effect of the medication if the
client reports the absence of which symptom?
1. Diarrhea
2.
Heartburn
3. Flatulence
4. Constipation
Heartburn
Rationale: Omeprazole is a proton pump inhibitor
classified
as an antiulcer agent. The intended effect of the
medication is
relief of pain from gastric irritation, often
called heartburn by
clients. Omeprazole is not used to treat the
conditions identified in options 1, 3, and 4.
A client with gastritis who uses nonsteroidal antiinammatory drugs
(NSAIDs) has been taking misoprostol. The nurse determines that the
misoprostol
is having the intended therapeutic effect if
which
finding is noted?
1. Resolved diarrhea
2. Relief
of epigastric pain
3. Decreased platelet count
4. Decreased
white blood cell count
2. Relief of epigastric pain
Rationale: The client who uses NSAIDs is prone to
gastric
mucosal injury. Misoprostol is a gastric protectant and
is given
specifically to prevent this occurrence in clients
taking NSAIDs
frequently. Diarrhea can be a side effect of the
medication but
is not an intended effect. Options 3 and 4 are
unrelated to the
purpose of misoprostol.
A client with a gastric ulcer has a prescription for
sucralfate
1 gram by mouth 4 times daily. The
nurse would schedule the
medication for which
times?
1. With meals and at
bedtime
2. Every 6 hours around the clock
3. One hour after
meals and at bedtime
4. One hour before meals and at bedtime
4. One hour before meals and at bedtime
Rationale: Sucralfate is a gastric protectant. The
medication
would be scheduled for administration 1 hour before
meals
and at bedtime. The medication is timed to allow it to form
a
protective coating over the ulcer before food intake
stimulates
gastric acid production and mechanical irritation. The
other
options are incorrect.
An older client with peptic ulcer disease recently has
been
taking cimetidine. The nurse monitors the client for which most
frequent central nervous system
side effect of this
medication?
1. Tremors
2. Dizziness
3.
Confusion
4. Hallucinations
3. Confusion
Rationale: Cimetidine is a histamine (H2)-receptor
antagonist. Older clients are especially susceptible to central
nervous system side effects of cimetidine. The most frequent
of
these is confusion. Less common central nervous system
side
effects include headache, dizziness, drowsiness, and hallucinations.
A client with chronic pancreatitis has begun medication therapy with
pancrelipase. The nurse evaluates
that the medication is having
the optimal intended
benefit if which effect is observed?
1.
Weight loss
2. Relief of heartburn
3. Reduction of
steatorrhea
4. Absence of abdominal pain
3. Reduction of steatorrhea
Rationale: Pancrelipase is a pancreatic enzyme used
in clients
with pancreatitis as a digestive aid. The medication
would
reduce the amount of fatty stools (steatorrhea).
Another
intended effect could be improved nutritional status. It
is not
used to treat abdominal pain or heartburn. Its use could
result
in weight gain but would not result in weight loss if it
is aiding
in digestion
A client with gastroenteritis has an as-needed prescription for
ondansetron. For which condition(s)
would the nurse administer
this medication?
1. Paralytic ileus
2. Incisional
pain
3. Urinary retention
4. Nausea and vomiting
4. Nausea and vomiting
Rationale: Ondansetron is an antiemetic used to treat
postoperative nausea and vomiting, as well as nausea and
vomiting
associated with chemotherapy. The other options are
incorrect
reasons for administering this medication
A client with gastroenteritis has an as-needed prescription for
loperamide hydrochloride. For which
condition would the nurse
administer this medication?
1. Constipation
2. Abdominal
pain
3. An episode of diarrhea
4. Hematest-positive
nasogastric tube drainage
3. An episode of diarrhea
Rationale: Loperamide is an antidiarrheal agent. It
is used
to manage acute and chronic diarrhea in conditions such
as
inflammatory bowel disease. Loperamide also can be used
to
reduce the volume of drainage from an ileostomy. It is
not
used for the conditions in options 1, 2, and 4.
A client with Crohn’s disease is scheduled to receive an infusion of
infliximab. What intervention
by the nurse will determine the
effectiveness of
treatment?
1. Monitoring the leukocyte
count for 2 days after
the infusion
2. Checking the
frequency and consistency of bowel movements
3. Checking serum
liver enzyme levels before and
after the infusion
4.
Carrying out a Hematest on gastric uids after
the infusion is completed
2. Checking the frequency and consistency of bowel movements
Rationale: The principal manifestations of Crohn’s
disease
are diarrhea and abdominal pain. Infliximab is an
immunomodulator that reduces the degree of inflammation in
the
colon, thereby reducing the diarrhea. Options 1, 3, and 4
are
unrelated to this medication.