Chapter 12: Gastrointestinal and Nutritional Problems

Question 1

The charge nurse is reviewing the medication administration records for several clients. Which situation needs to be brought to the attention of the prescribing health care provider?

1. A client with gastroesophageal reflux disease is receiving magnesium hydroxide.
2. An older adult client with new-onset constipation is getting psyllium three times a day.
3. A client who needs a bowel prep is getting polyethylene glycol-electrolyte solution.
4. A client with abdominal pain secondary to diverticulitis is receiving bisacodyl.

Answer 1

Ans: 4
Laxatives should not be administered to clients with undiagnosed abdominal pain, cramps, or nausea. Appendicitis, diverticulitis, ulcerative colitis, acute surgical abdomens, and bowel obstruction are also contraindications. The other clients are receiving medications that are appropriate for their conditions. Focus: Prioritization.

Question 2

When a client is being prepared for a colonoscopy procedure, which task is most suitable to delegate to unlicensed assistive personnel (UAP)?

1. Explaining the need for a clear liquid diet
2. Reinforcing “NPO” status
3. Administering laxatives as needed
4. Administering an enema to prepare the bowel

Answer 2

Ans: 2
The UAP can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the UAP can administer the enema; however, special training is required, and policies may vary among institutions. Medication administration should be performed by licensed personnel. Focus: Delegation.

Question 3

The nurse is reviewing medication lists for clients who are being treated for peptic ulcer disease (PUD). The nurse is most likely to question the use of which medication?

1. Ibuprofen
2. Omeprazole
3. Amoxicillin
4. Clarithromycin

Answer 3

Ans: 1
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID), and NSAIDs are thought to be one of the aggravating factors of PUD. Omeprazole, amoxicillin, and clarithromycin are used as a triple combination therapy for treatment of PUD. Focus: Prioritization; Test Taking Tip: NSAIDs are commonly prescribed and self-selected as over-the-counter medications; thus, knowing the pharmacology, drug–drug interactions, and side effects are worthwhile for test taking purposes and clinical practice.

Question 4

The nurse would be most concerned about a prescription for a total parenteral nutrition (TPN) fat emulsion for a client with which condition?

1. Gastrointestinal (GI) obstruction
2. Severe anorexia nervosa
3. Chronic diarrhea and vomiting
4. Fractured femur

Answer 4

Ans: 4
A client with a fractured femur is at risk for fat embolism, so a fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used in clients with GI obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization.

Question 5

The nurse is preparing to administer total parenteral nutrition (TPN) through a central line. Place the following steps for administration in the correct order.

1. Thread the IV tubing through an infusion pump.
2. Check the solution for cloudiness or turbidity.
3. Connect the tubing to the central line, using aseptic technique.
4. Select and flush the correct tubing and filter.
5. Set the infusion pump at the prescribed rate.
6. Confirm the order for TPN before administration.

Answer 5

Ans: 6, 2, 4, 1, 3, 5
The nurse should always check the order before administering TPN; generally, each bag is individually prepared by the pharmacist. The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization.

Question 6

The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment finding is the most serious?

1. Projectile vomiting
2. Burning sensation 2 hours after eating
3. Coffee-ground emesis
4. Boardlike abdomen with shoulder pain

Answer 6

Ans: 4
A boardlike abdomen with shoulder pain is a symptom of a perforation, which is the most lethal complication of PUD. A burning sensation is a typical report and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding, and the client will require diagnostic testing. Focus: Prioritization.

Question 7

The nurse is taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon?

1. Obesity for approximately 5 years
2. History of counseling for body dysmorphic disorder
3. Failure to reduce weight with other forms of therapy
4. Body weight 100% above the ideal for age, gender, and height

Answer 7

Ans: 2
Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other findings are criterion indicators for this treatment. Focus: Prioritization.

Question 8

The nurse is taking report on an elderly client who was admitted with abdominal pain and nausea, vomiting, and diarrhea. The client also has a history of chronic dementia. Which comment by the night shift nurse is most concerning?

1. The client has a flat affect and rambling and repetitive speech.
2. The client has memory impairments and thinks the year is 1948.
3. The client lacks motivation and demonstrates early morning awakening.
4. The client has a fluctuating level of consciousness and mood swings.

Answer 8

Ans: 4
Fluctuating level of consciousness and mood swings are associated more with acute delirium, which could be caused by many things, such as electrolyte imbalances, sepsis, or medications. Information about the client’s baseline behavior is essential; however, based on knowledge of pathophysiology, the nurse knows that flat affect and rambling and repetitive speech, memory impairments, and disorientation to time are behaviors typically associated with chronic dementia. Lack of motivation and early morning awakening are associated with depression. Focus: Prioritization; Test Taking Tip: A sudden change in level of consciousness and mental status signal a need to conduct further assessment for an acute process. This question requires the ability to differentiate between acute and chronic disease processes and accompanying symptoms.

Question 9

In the care of a client with gastroesophageal reflux disease, which task would be appropriate to delegate to unlicensed assistive personnel (UAP)?

1. Sharing successful strategies for weight reduction
2. Encouraging the client to express concerns about lifestyle modification
3. Reminding the client not to lie down for 2 to 3 hours after eating
4. Explaining the rationale for eating small frequent meals

Answer 9

Ans: 3
Reminding the client to follow through on advice given by the nurse is an appropriate task for the UAP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing client concerns. Focus: Delegation.

Question 10

The client needs diagnostic testing to confirm symptoms of peptic ulcer disease (PUD), and the health care provider tells the nurse that the client prefers noninvasive methods. Which brochure is the nurse most likely to prepare for the client?
1. “Three Simple Ways to Detect H. pylori Using Your Blood, Breath, or Stool.”
2. “How Your Doctor Uses a Chest and Abdomen X-ray Series to Detect
PUD.”
3. “Esophagogastroduodenoscopy: The Major Diagnostic Test for PUD.”
4. “Common Questions and Answers About Nuclear Medicine Scans.”

Answer 10

Ans: 1
H. pylori is frequently associated with PUD, and the organism can be detected through breath, blood, or stool. Esophagogastroduodenoscopy is the best test for PUD; however, it is considered an invasive procedure. Chest and abdominal series may be ordered if perforation is suspected, and a nuclear medicine scan may be ordered if gastrointestinal bleeding is present. Focus: Prioritization.

Question 11

The nurse is providing the immediate postoperative care for a client who had fundoplication to reinforce the lower esophageal sphincter for the purpose of a hiatal hernia repair. What is the priority action for the care of this client?

1. Elevate the head of the bed at least 30 degrees.
2. Assess the nasogastric tube for yellowish-green drainage.
3. Assist the client to start taking a clear liquid diet.
4. Assess the client for gas bloat syndrome.

Answer 11

Ans: 1
The primary concern in the immediate postoperative period is the potential for airway complications. Elevating the head at least 30 degrees decreases the chance for aspiration and facilitates respiratory effort. The other options are also correct but will occur later in the postoperative period. Focus: Prioritization.

Question 12

A client with chronic hepatitis C has been taking the antiviral medication ledipasvir–sofosbuvir daily for the past month. Which information gathered during a home visit is most important for the nurse to communicate to the health care provider?

1. The client reports frequent headaches.
2. The client complains of feeling chronically tired.
3. The client occasionally misses a dose of the medication.
4. The client always takes the medication just before eating.

Answer 12

Ans: 3
Effective treatment of chronic hepatitis C requires careful adherence to the medication regimen for the entire treatment time (usually 12 weeks). Headache and fatigue are common adverse effects of ledipasvir–sofosbuvir, and the medication can be taken with or without food. Focus: Prioritization.

Question 13

Which client is the most appropriate to assign to an LPN/LVN under the supervision of an RN?

1. A client with oral cancer who is scheduled in the morning for glossectomy
2. An obese client returned from surgery after a vertical banded gastroplasty
3. A client with anorexia nervosa who has muscle weakness and decreased urine output
4. A client with intermittent nausea and vomiting related to chemotherapy

Answer 13

Ans: 4
Nausea and vomiting are common after chemotherapy. Administration of antiemetics and fluid monitoring can be done by an LPN/LVN. The RN should perform the preoperative teaching for the glossectomy client. Clients returning from surgery need extensive assessment. The client with anorexia is showing signs of hypokalemia and is at risk for cardiac dysrhythmias. Focus: Assignment.

Question 14

For clients with peptic ulcer disease (PUD), what is the most important lifestyle modification?

1. Avoiding caffeine
2. Decreasing alcohol intake
3. Smoking cessation
4. Controlling stress

Answer 14

Ans: 3
Smoking is associated with PUD. The other lifestyle modifications may be desirable, but the current evidence does not show strong linkage to the development of or recovery from PUD. Focus: Prioritization.

Question 15

The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader?

1. Obtaining an oversized blood pressure cuff and a large-size bed
2. Setting up a reinforced trapeze bar
3. Assisting in the planning of toileting, turning, and ambulation
4. Assigning tasks to unlicensed assistive personnel (UAP) and other ancillary staff

Answer 15

Ans: 3
The LPN/LVN can offer valuable assistance in planning the interventions, but the RN has ultimate responsibility for the care plan. The LPN/LVN can delegate and assign tasks to UAPs; however, if the RN is the team leader, it is better if UAPs are not receiving instructions from multiple people. Obtaining equipment should be delegated to a UAP. A physical therapist should be contacted to set up specialized equipment. Focus: Assignment.

Question 16

A client with proctitis needs a rectal suppository. A senior nursing student assigned to care for this client tells the nurse that she is afraid to insert a suppository because she has never done it before. What is the most appropriate action in supervising this student?

1. Give the medication and tell the student to talk to the instructor.
2. Ask the student to leave the clinical area because she is unprepared.
3. Reassign the client to an LPN/LVN and send the student to observe.
4. Show the student how to insert the suppository and talk to the instructor.

Answer 16

Ans: 4
Showing the student how to insert the suppository meets both the immediate client need and the student’s learning need. The instructor can address the student’s fears and long-term learning needs after he or she is aware of the incident. It is preferable that students express fears and learning needs. The other options will discourage the student’s future disclosure of clinical limitations and need for additional training. Focus: Supervision, Assignment.

Question 17

The nurse is teaching the client and family how to perform colostomy irrigation. Place the following information in the correct order.

1. Hang the container at about shoulder height.
2. Allow solution to flow slowly and steadily for 5 to 10 minutes.
3. Don clean gloves and put 500 to 1000 mL of lukewarm water in the container.
4. Lubricate the stoma cone and gently insert the tubing tip into the stoma.
5. Clean, rinse, and dry the skin, and apply a new drainage pouch.
6. Allow 15 to 20 minutes for initial evacuation; then the client should walk for 30 to 45 minutes for secondary evacuation.

Answer 17

Ans: 3, 1, 4, 2, 6, 5
Putting on a pair of clean gloves protects the hands from colostomy secretions. The water should be warm (cold water can cause cramping), and the container should be hung at shoulder height (hanging the container too high or too low will alter the rate of flow). Lubricating the stoma and gently inserting the tubing tip will allow the water to flow into the stoma. A slow and steady flow prevents cramps and spillage. Providing adequate time allows for complete evacuation. Walking stimulates the bowel. Careful attention to the skin prevents breakdown. Focus: Prioritization.

Question 18

The nurse is caring for a client with a nasogastric (NG) tube. Which task can be delegated to experienced unlicensed assistive personnel (UAP)?

1. Removing the NG tube at the prescribed time
2. Securing the tape if the client accidentally dislodges the tube
3. Disconnecting the suction to allow ambulation to the toilet
4. Reconnecting the suction after the client has ambulated

Answer 18

Ans: 3
Disconnecting the tube from suction is an appropriate task to delegate. (The nurse must give specific instructions or verify that the UAP knows how to do this task.) Suction should be reconnected by the nurse so that correct pressure is checked. If the UAP is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured. Focus: Delegation.

Question 19

The nurse is planning a treatment and prevention program for chronic bowel incontinence for an elderly client. Which intervention should the nurse try first?

1. Administer a glycerin suppository 15 minutes before evacuation time.
2. Insert a rectal tube at specified intervals each day.
3. Assist the client to the commode or toilet 30 minutes after meals.
4. Use incontinence briefs or adult-sized diapers.

Answer 19

Ans: 3
The goal of bowel training is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal. If this is not successful, a suppository can be used to stimulate the urge. The use of incontinence briefs is embarrassing for the client, and they must be changed frequently to prevent skin breakdown. Routine use of rectal tubes is not recommended because of the potential for damage to the mucosa and sphincter tone. Focus: Prioritization.

Question 20

A client hospitalized with ulcerative colitis reports 10 to 20 small diarrhea stools per day, with abdominal pain before defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing concept to consider when planning interventions for this client?

1. Elimination
2. Nutrition
3. Pain
4. Adherence

Answer 20

Ans: 1
The immediate problem is controlling the diarrhea. Addressing this problem is a step toward correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and adherence with the treatment plan are important long-term goals that can be addressed when the client is feeling better physically. Focus: Prioritization.

Question 21

While transferring a dirty laundry bag, an unlicensed assistive personnel (UAP) sustains a puncture wound to the finger from a contaminated needle. The unit has several clients with hepatitis and acquired immunodeficiency syndrome; the needle source is unknown. Place the following instructions, for the UAP, in the correct order of priority.

1. Have blood test(s) performed per protocol.
2. Complete and file an incident report.
3. Perform a thorough aseptic hand washing.
4. Report to the occupational health nurse.
5. Follow up for laboratory results and counseling.
6. Begin prophylactic drug therapy.

Answer 21

Ans: 3, 4, 1, 6, 2, 5
Immediate decontamination is appropriate because exposure time can affect viral load. The occupational health nurse will direct the UAP to get the appropriate laboratory tests, obtain prophylaxis within 72 hours (the sooner the better), file the correct forms, and follow up on results. Focus: Prioritization, Supervision.

Question 22

The home health nurse sees that the client is taking cimetidine. What question is the nurse most likely to ask to evaluate the efficacy of the therapy?

1. “Are you still having problems with constipation?”
2. “Has the medication helped to relieve the acid indigestion?”
3. “Did the medication relieve the nausea and vomiting?”
4. “Do you feel like your appetite has improved?”

Answer 22

Ans: 2
Cimetidine is available over the counter and is used to relieve heartburn, acid indigestion, and sour stomach. Focus: Prioritization.

Question 23

The nurse is caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, “Something popped open.” Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication.

1. Cover the intestine with sterile moistened gauze.
2. Stay calm and stay with the client.
3. Check the vital signs, especially blood pressure and pulse.
4. Have a colleague gather sterile supplies and contact the health care provider (HCP).
5. Put the client into semi-Fowler position with knees slightly flexed.
6. Prepare the client for surgery as ordered.

Answer 23

Ans: 2, 5, 3, 4, 1, 6
Stay calm and stay with the client. Any increase in intra- abdominal pressure will worsen the evisceration; placement of the client in a semi-Fowler position with knees flexed will decrease the strain on the wound site. (Note: If shock develops, the client’s head should be lowered.) Continuously monitor vital signs (particularly for a decrease in blood pressure or increase in pulse rate) while a colleague gathers supplies and notifies the HCP. Covering the site protects tissue. Ultimately, the client will need emergency surgery. Focus: Prioritization.

Question 24

The nurse is providing postoperative care for a client who underwent laparoscopic cholecystectomy. What should be reported immediately to the health care provider?

1. The client cannot void 5 hours postoperatively.
2. The client reports shoulder pain.
3. The client reports right upper quadrant pain.
4. Output does not equal input for the first few hours.

Answer 24

Ans: 3
Right upper quadrant pain is a sign of hemorrhage or bile leakage. The ability to void should return within 6 hours postoperatively. Right shoulder pain is related to unabsorbed carbon dioxide and will be resolved by placing the client in a Sims position. For the first several hours after surgery, output is not expected to equal input. Focus: Prioritization.

Question 25

An older adult client tells the home health nurse that he puts 17 g of polyethylene glycol in a large cup of coffee every morning. Which assessment is the nurse most likely to perform first?

1. Assess the client for signs of dehydration or electrolyte imbalances.
2. Assess for signs and symptoms of overdose and then call Poison Control.
3. Ask the client to describe frequency and consistency of bowel movements.
4. Ask the client what he understands about the purpose of the medication.

Answer 25

Ans: 3
The client is taking the recommended dose of polyethylene glycol. Polyethylene glycol is used for the treatment of chronic constipation, so the nurse would assess the effect that the medication is having on bowel movements. Reviewing understanding of medications is always a good idea if the nurse has time. Older adult clients generally have a greater risk for dehydration and fluid and electrolyte imbalances, so this should be a routine assessment. Focus: Prioritization.

Question 26

In the care of a client with acute viral hepatitis, which task should be delegated to unlicensed assistive personnel (UAP)?

1. Emptying the bedpan while wearing gloves
2. Playing games or engaging the client in diversional activities
3. Monitoring dietary preferences
4. Reporting signs and symptoms of jaundice

Answer 26

Ans: 1
The UAP should use infection control precautions for the protection of self, employees, and other clients. Monitoring is an RN responsibility. UAPs can report valuable information; however, they are not responsible for detecting signs and symptoms that can be subtle or hard to detect, such as skin changes. Although playing games with the client may be ideal, it is rarely possible on a medical-surgical unit. Focus: Delegation.

Question 27

The nurse is caring for a client with cirrhosis and portal hypertension. Which statement by the client is cause for greatest concern?

1. “I’m very constipated and have been straining during bowel movements.”
2. “I can’t button my pants anymore because my belly is so swollen.”
3. “I have a tight sensation in my lower legs when I forget to put my feet up.”
4. “When I sleep, I have to sit in a recliner so that I can breathe more easily.”

Answer 27

Ans: 1
There is a potential for sudden rupture of fragile blood vessels with massive hemorrhage because straining increases thoracic or abdominal pressure. The client could have fluid accumulation in the abdomen (ascites) that can be mild and hard to detect or severe enough to cause orthopnea. Dependent peripheral edema can also be observed but is less urgent. Focus: Prioritization.

Question 28

For clients coming to the ambulatory care gastrointestinal clinic, which task would be most appropriate to assign to an LPN/LVN?

1. Teaching a client self-care measures for an ulcer
2. Assisting the health care provider to incise and drain a pilonidal cyst
3. Evaluating a client’s response to sitz baths for an anorectal abscess
4. Describing the basic pathophysiology of an anal fistula to a client

Answer 28

Ans: 2
Assisting with procedures for clients in stable condition with predictable outcomes is within the educational preparation of the LPN/LVN. Teaching the client about self-care or pathophysiology and evaluating the outcome of interventions are responsibilities of the RN. Focus: Assignment.

Question 29

A client underwent an exploratory laparotomy 2 days ago. The health care provider (HCP) should be called immediately for which physical assessment finding?

1. Abdominal distention and rigidity
2. Displacement of the nasogastric (NG) tube
3. Absent or hypoactive bowel sounds
4. Nausea and occasional vomiting

Answer 29

Ans: 1
Distention and rigidity can signal hemorrhage or peritonitis. The HCP may also decide that these symptoms require a medication to stimulate peristalsis. Absence of bowel sounds is expected within the first 24 to 48 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and a PRN prescription for an antiemetic is usually part of the routine postoperative prescriptions. The NG tube should be assessed for displacement, and the correct position of the tube must be confirmed. The nurse then secures the tube as necessary. Focus: Prioritization.

Question 30

The nurse must rearrange the room assignments for clients. Which clients would be best to put in the same room? Select all that apply.

1. A 35-year-old woman with copious intractable nausea and vomiting
2. A 43-year-old woman who underwent cholecystectomy 2 days ago
3. A 53-year-old woman with pain related to alcohol-associated pancreatitis
4. A 62-year-old woman with colon cancer receiving chemotherapy and radiation
5. A 70-year-old woman with stool culture results that show Clostridium difficile
6. A 55-year-old woman who is having symptoms after an exposure to norovirus

Answer 30

Ans: 2, 3
The client who had a cholecystectomy and the client with pancreatitis will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting frequently need contact isolation. Clostridium difficile is frequently identified in health care-acquired infections. Norovirus is highly contagious and symptoms include abdominal pain, vomiting, and diarrhea. Clients with cancer receiving chemotherapy are at risk for immunosuppression and are likely to need protective isolation. Focus: Assignment.

Question 31

The nurse is caring for a client who was recently admitted for severe diverticulitis. Which task is appropriate to delegate or assign for the care of this client?

1. Tell the unit secretary to call radiology and schedule a barium enema.
2. Ask the LPN/LVN to give as needed (PRN) laxatives when the client reports constipation.
3. Instruct the nursing student to help the client ambulate up and down the hall.
4. Tell unlicensed assistive personnel to save a stool specimen to test for occult blood.

Answer 31

Ans: 4
Diverticulitis can cause chronic or severe bleeding, so if there is no obvious blood in the stool, the stool may be tested for occult blood. A barium enema is not usually ordered because of the danger of perforation. Laxatives and ambulation increase intestinal motility and are to be avoided in the initial phase of treatment. If a barium enema, PRN laxative, or ambulation are prescribed, the nurse should check with the health care provider before delegating these interventions. Focus: Delegation.

Question 32

The nurse is caring for a client who was admitted to the medical-surgical unit for observation after being evaluated in the emergency department for blunt trauma to the abdomen. Which instructions are appropriate to give to unlicensed assistive personnel (UAP)?

1. Check the client’s skin temperature and report if the skin feels cool.
2. Check urometer every hour and observe for red- or pink-tinged urine.
3. Check vital signs every hour and report all of the values.
4. Check the client’s pain and report worsening of pain or discomfort.

Answer 32

Ans: 3
The UAP can take vital signs and report all of the values to the RN. In this case, all of the values are needed to detect trends. In other cases, the nurse may decide to give parameters for reporting. The RN should assess skin temperature and pain and closely monitor the urine because quantity is an indicator of perfusion and fluid status. Red or pink urine can signal damage to the urinary system, transfusion reaction, or rhabdomyolysis. Focus: Delegation.

Question 33

Place the steps for performing colostomy care in the correct order.

1. Fit the pouch snugly around the stoma.
2. Assess the color and appearance of the stoma.
3. Wash the skin with mild soap and rinse with warm water.
4. Apply a skin barrier to protect the peristomal skin.
5. Dry the skin carefully.
6. Don a pair of clean gloves and remove the old pouch.

Answer 33

Ans: 6, 2, 3, 5, 4, 1
A pair of clean gloves should be put on before touching the skin or pouch. The stoma should be assessed for a healthy pink color. Washing, rinsing, and drying the skin and applying a skin barrier help to protect the skin. A good fit prevents gastric contents from spilling onto the skin. Focus: Prioritization; Test Taking Tip: Mental rehearsal is a learning technique that helps in acquiring a new skill. Mentally visualizing each step is also useful in answering this type of question.

Question 34

Clients who are undernourished or starved for prolonged periods are at risk for refeeding syndrome when nourishment is first given. What is the priority nursing assessment to prevent complications associated with this syndrome?

1. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention.
2. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention.
3. Observe for signs of secret purging and ingestion of water to increase weight.
4. Assess for alternating constipation and diarrhea and pale clay-colored stools.

Answer 34

Ans: 1
Refeeding syndrome occurs when aggressive and rapid feeding results in fluid retention and heart failure. Electrolytes, especially phosphorus, should be monitored, and the client should be observed for signs of fluid overload. Changes in bowel sounds, nausea, and distention may occur but are also appropriate for any client with nutritional issues or for clients receiving enteral feedings. Observing for purging and water ingestion would be appropriate for a client with an eating disorder. Changes in stool patterns may occur but are not related to refeeding syndrome. Focus: Prioritization.

Question 35

The nurse is caring for a client who was admitted for advanced cirrhosis. The client has massive ascites, peripheral dependent edema in the lower extremities, nausea and vomiting, and dyspnea related to pressure on the diaphragm. Which indicator is the most reliable for tracking fluid retention?

1. Auscultating the lung fields for crackles every day
2. Measuring the abdominal girth every morning
3. Performing daily weights with the same amount of clothing
4. Checking the extremities for pitting edema and comparing with baseline

Answer 35

Ans: 3
All of these measures should be performed for total care of the client; however, weighing the client every day is considered the single best indicator of fluid volume. Focus: Prioritization; Test Taking Tip: In studying for the NCLEX® Examination, don’t neglect fundamentals textbooks. This question is based on fundamental knowledge of fluids and fluid management.

Question 36

The nurse hears in hand-off report that, 1 hour ago, the health care provider requested that the client be given the maximum dose of magnesium hydroxide. Which instruction is the nurse most likely to give to unlicensed assistive personnel?

1. Client will frequently need assistance to the bathroom for bowel evacuation.
2. Client may experience some dizziness when ambulating or changing position.
3. Client is frequently vomiting and may need linen and gown changes.
4. Client needs to be encouraged and assisted to eat and drink as much as possible.

Answer 36

Ans: 1
The maximum dose of magnesium hydroxide is given for bowel evacuation and cleansing. It is expected that the medication should have effect within 2 to 6 hours. Focus: Supervision.

Question 37

A client with end-stage liver disease is talking to the nurse about being on the transplant list. Which statement by the client is cause for greatest concern?

1. “I have a family history of diabetes.”
2. “I had symptoms of asthma when I was a kid.”
3. “I guess I should cut back on my alcohol consumption.” 4. “I am not very good about taking prescribed medication.”

Answer 37

Ans: 3
Substance abuse may exclude a person from the transplant list, so the nurse should conduct additional assessment about this comment. The comment about difficulty in taking prescription medications should also be investigated because a true inability to follow the treatment regimen would also exclude the client from the list. Focus: Prioritization.

Question 38

The nursing is supervising a nursing student who is caring for a client who had a cholecystectomy. There is a T-tube in place. The nurse would intervene if the student performs which action?

1. Maintains the client in a semi-Fowler position
2. Checks the amount, color, and consistency of the drainage
3. Gently aspirates the drainage from the tube
4. Inspects the skin around the tube for redness or irritation

Answer 38

Ans: 3
T-tubes should not be irrigated, aspirated, or clamped without specific directions from the health care provider. All of the other actions are appropriate in the care of this client. Focus: Supervision.

Question 39

An older adult client tells the home health nurse that she is taking methylcellulose for chronic constipation. Which behavior is cause for greatest concern?

1. Client primarily eats white bread and drinks low-fat milk. 2. Client takes the methylcellulose three times a day.
2. Client takes the medication with a few sips of water.
3. Client does not promptly act on the urge to defecate.

Answer 39

Ans: 3
Methylcellulose can cause esophageal obstruction if taken with insufficient amounts of fluid. Intestinal obstruction is also a possibility if the passage is slowed or impeded. Three times a day is within the acceptable dose range. High fiber and a prompt response to urge to defecate should be encouraged to restore natural and normal bowel movements. Focus: Prioritization.

Question 40

A male nurse tells an older male client that he needs to perform a digital examination of the rectum to check for possible fecal impaction. The client responds, “I’m not letting any homosexual get near me.” What should the nurse do first?

1. Explain that the procedure is a nursing action, not a sexual advance.
2. Ask the charge nurse to reassign that client to a different nurse.
3. Document that the client refused to allow the examination.
4. Ask the client if the presence of a female staff member would be acceptable.

Answer 40

Ans: 4
The nurse is likely to feel upset, even angry; however, ideally, the nurse focuses on the client and tries to find a solution that allows the care to continue. Having a female witness in the room may reassure the client that nothing untoward will happen. If the client continues to express hostility and rejection, then the nurse could ask the charge nurse to reassign the client. In cases, of emergency, the nurse would acknowledge the client’s feelings but firmly explain that the intervention can’t be delayed. (e.g., “I see you are displeased, but this __________ has to be done right now.”) All attempts and interventions should be documented. Focus: Prioritization.

Question 41

The client has portal hypertension and hepatic encephalopathy secondary to liver disease and is being treated with lactulose. Which laboratory result will the nurse check first to see if the medication is having the desired effect?

1. White blood cell count
2. Ammonia level
3. Potassium level
4. Platelet count

Answer 41

Ans: 2
The healthy liver breaks down ammonia, but in liver disease, the ammonia accumulates, and serum levels increase. Lactulose helps by enhancing intestinal excretion of ammonia. Focus: Prioritization.