Ch. 55 Flashcards
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client’s abdomen is tense and rigid. What action takes priority?
a.
Administer the prescribed pain medication.
b.
Notify the health care provider immediately.
c.
Percuss all four abdominal quadrants.
d.
Take and document a set of vital signs.
ANS: B
This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.
DIF: Applying/Application REF: 1132
A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority?
a.
Document the findings in the chart.
b.
Request an electrocardiogram (ECG).
c.
Facilitate a serum potassium test.
d.
Place the client on bedrest.
ANS: B
Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.
DIF: Analyzing/Analysis REF: 1132
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client’s blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?
a.
Administer ibuprofen (Motrin).
b.
Call the Rapid Response Team.
c.
Start a large-bore IV with normal saline.
d.
Tell the client to remain lying down.
ANS: C
This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.
DIF: Applying/Application REF: 1136
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate?
a.
Assess the client for iodine or shellfish allergies.
b.
Educate the client on the side effects of sedation.
c.
Inform the client a second scan may be needed.
d.
Teach the client about bowel preparation for the scan.
ANS: C
A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.
DIF: Understanding/Comprehension REF: 1134
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is most important?
a.
Alcohol intake of 1 to 2 drinks per week
b.
Family history of H. pylori infection
c.
Former smoker still using nicotine patches
d.
Willingness to adhere to drug therapy
ANS: D
Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client’s willingness and ability to follow the regimen. The other assessment findings are not as critical.
DIF: Applying/Application REF: 1127
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client?
a.
Check with the pharmacist before taking other medications.
b.
Increase intake of calcium and vitamin D.
c.
Report any worsening of symptoms to the provider.
d.
Take the medication as prescribed by the provider.
ANS: B
All of this advice is appropriate for any client taking this medication. However, long-term use is associated with osteoporosis and osteoporosis-related fractures. This client is already at higher risk for this problem and should be instructed to increase calcium and vitamin D intake. The other options are appropriate for any client taking any medication and are not specific to the use of esomeprazole.
DIF: Applying/Application REF: 1130
The nurse caring for clients with gastrointestinal disorders should understand that which category best describes the mechanism of action of sucralfate (Carafate)?
a.
Gastric acid inhibitor
b.
Histamine receptor blocker
c.
Mucosal barrier fortifier
d.
Proton pump inhibitor
ANS: C
Sucralfate is a mucosal barrier fortifier (protector). It is not a gastric acid inhibitor, a histamine receptor blocker, or a proton pump inhibitor.
DIF: Remembering/Knowledge REF: 1135
A nurse answers a client’s call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first?
a.
Assist the client back to bed.
b.
Notify the provider immediately.
c.
Put on a pair of gloves.
d.
Take a set of vital signs.
ANS: C
All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid contamination with blood or body fluids.
DIF: Applying/Application REF: 1128
A client had an upper gastrointestinal hemorrhage and now has a nasogastric (NG) tube. What comfort measure may the nurse delegate to the unlicensed assistive personnel (UAP)?
a.
Lavaging the tube with ice water
b.
Performing frequent oral care
c.
Re-positioning the tube every 4 hours
d.
Taking and recording vital signs
ANS: B
Clients with NG tubes need frequent oral care both for comfort and to prevent infection. Lavaging the tube is done by the nurse. Re-positioning the tube, if needed, is also done by the nurse. The UAP can take vital signs, but this is not a comfort measure.
DIF: Applying/Application REF: 1136
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately?
a.
Albumin: 2.1 g/dL
b.
Hematocrit: 28%
c.
Hemoglobin: 8.1 mg/dL
d.
International normalized ratio (INR): 4.2
ANS: D
An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.
DIF: Applying/Application REF: 1140
A client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate?
a.
“Do you have family or friends for support?”
b.
“I’d like to know what you are feeling now.”
c.
“Well, we knew this would probably happen.”
d.
“Would you like me to refer you to hospice?”
ANS: B
The nurse assesses the client’s emotional state with open-ended questions and statements and shows a willingness to listen to the client’s concerns. Asking about support people is very limited in nature, and “yes-or-no” questions are not therapeutic. Stating that this was expected dismisses the client’s concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.
DIF: Applying/Application REF: 1139
A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best?
a.
“Slippery elm has no benefit for this problem.”
b.
“Slippery elm is often used for this disorder.”
c.
“There is no evidence that this will work.”
d.
“You should not take any herbal remedies.”
ANS: B
There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this disorder.
DIF: Understanding/Comprehension REF: 1131
A nurse is teaching a client about magnesium hydroxide with aluminum hydroxide (Maalox). What instruction is most appropriate?
a.
“Aspirin must be avoided.”
b.
“Do not worry about black stools.”
c.
“Report diarrhea to your provider.”
d.
“Take 1 hour before meals.”
ANS: C
Maalox can cause hypermagnesemia, which causes diarrhea, so the client should be taught to report this to the provider. Aspirin is avoided with bismuth sulfate (Pepto-Bismol). Black stools can be caused by Pepto-Bismol. Maalox should be taken after meals.
DIF: Understanding/Comprehension REF: 1129
For which client would the nurse suggest the provider not prescribe misoprostol (Cytotec)?
a.
Client taking antacids
b.
Client taking antibiotics
c.
Client who is pregnant
d.
Client over 65 years of age
ANS: C
Misoprostol can cause abortion, so pregnant women should not take this drug. The other clients have no contraindications to taking misoprostol.
DIF: Remembering/Knowledge REF: 1129
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?
a.
Arrange a dietary consult.
b.
Increase fluid intake.
c.
Limit the client’s foods.
d.
Make the client NPO.
ANS: A
The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.
DIF: Applying/Application REF: 1140
