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NCLEX: Prioritization, Delegation, And Assignment 5th Edition > GI > Flashcards

GI Flashcards

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1
Q

Which is inappropriate

  1. GERD receiving magnesium hydroxide
  2. New onset Constipation receiving Psyllium x3 daily
  3. Bowel prep receiving polyethylene glyco-electrolyte
  4. Diverticulitis receiving Bisacodyl
A
  1. Diverticulitis receiving Bisacodyl

Laxatives are Contradicted for Ab pain, nausea, appendicitis, diverticulitis, UC, acute surgery, bowel obstruction

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2
Q

Colonoscopy which is most appropriate for a UAP

  1. Explain need for clear liquids
  2. Reinforce NPO status
  3. Admin Laxatives
  4. Admin enema
A
  1. Reinforce NPO status

Depending on state UAP can also give enemas

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3
Q

TPN administration
Put in correct order

  1. Thread IV tubing through IV infusion pump
  2. Check solution for cloudiness
  3. Connect tubing to central line, aseptic tech
  4. Select & flush the correct tubing & filter
  5. Set infusion pump at prescribed rate
  6. Confirm order fir TPN before admin
A
  1. Confirm order fir TPN before admin
  2. Check solution for cloudiness
  3. Select & flush the correct tubing & filter
  4. Thread IV tubing through IV infusion pump
  5. Connect tubing to central line, aseptic tech
  6. Set infusion pump at prescribed rate
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4
Q

PUD peptic ulcer disease. Most serious finding

  1. Projectile vomiting
  2. Burning sensation 2 hrs post eating
  3. Coffee-ground emesis
  4. Broadlike abdomen with shoulder pain
A
  1. Broadlike abdomen with shoulder pain

Symptom of perforation & most lethal

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5
Q

Immediate post-op
Fundoplication to reinforce lower esophageal sphincter for hiatal Hernia repair. Priority action

  1. HOB >30°
  2. Assess NG tube for yellowish drainage
  3. Assist client in taking clear fluid
  4. Assess for gas bloat syndrome
A
  1. HOB >30°

Immediate postop the concern is breathing.

Other answers are correct but will happen after

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6
Q

Most appropriate for LPN

  1. Oral cancer surgery scheduled for AM glossectomy
  2. Obese returned from surgery after vertical banded gastroplasty (endoscopic sleeve gastroplasty (ESG)
  3. Anorexia who has weakness & decreased urine output.
  4. Intermittent N/V related to chemotherapy
A
  1. Intermittent N/V related to chemotherapy - to be expected
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7
Q

Most important for PUD

  1. Avoid caffeine
  2. Decrease alcohol
  3. Stop smoking
  4. Controlling stress
A

Stop smoking

The others have no strong linkage to PUD

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8
Q

Postop morbid obese. Best for LPN under dirección of RN

  1. Obtaining oversized bed & BP cuff
  2. Setting up reinforced trapeze bar
  3. Assisting in the planning of toileting, turning, and ambulation
  4. Assigning task to UAP
A
  1. Assisting in the planning of toileting, turning, and ambulation

Physical therapy should install trapeze bar

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9
Q

Proctitis (inflammation of anus) client needs suppository. Senior nursing student is afraid to do so because she has never done it before. Which is the most appropriate response from RN preceptor

  1. Give the med & tell student to talk with instructor
  2. Ask student to leave because they are unprepared
  3. Reassign to an LPN & send student to observe
  4. Show student how to do it and talk to instructor
A
  1. Show student how to do it and talk to instructor

Meets both clients and students needs

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10
Q

Place in order Perform Colostomy irrigation.

  1. Hang container at shoulder height
  2. Allow solution to flow slowly for 5 - 10 minutes
  3. Don gloves & put 500 - 1000mL of lukewarm water in the container
  4. Lubricate stoma cone& gently insert tubing tip into stoma
  5. Clean, rinse, and dry skin apply new drainage pouch
  6. Allow 15 - 20 minutes for initial evacuation, client should walk 30 - 45 minutes for secondary evacuation.
A
  1. Don gloves & put 500 - 1000mL of lukewarm water in the container
  2. Hang container at shoulder height
  3. Lubricate stoma cone& gently insert tubing tip into stoma
  4. Allow solution to flow slowly for 5 - 10 minutes
  5. Allow 15 - 20 minutes for initial evacuation, client should walk 30 - 45 minutes for secondary evacuation.
  6. Clean, rinse, and dry skin apply new drainage pouch
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11
Q

Which can be Delegated to UAP

  1. Removal of NG tube at prescribed time
  2. Securing tape if client accidentally dislodged it.
  3. Disconnect suction to allow ambulation to bathroom
  4. Reconnect suction after ambulation
A
  1. Disconnect suction to allow ambulation to bathroom
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12
Q

Cimetidine

Class

Use

SE

Contradictions

A

Class: H² receptor Antagonist

Use: PUD, GERD,

SE Possible confusion in Elderly

Contradictions

Severe renal impairment (use with caution and possibly at lower doses)

Drugs that require gastric pH for absorption (e.g., ketoconazole, atazanavir)

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13
Q

Evisceration. Put steps in proper order

  1. Cover intestine with sterile moist gauze
  2. Stay calm & stay with client
  3. Check VS
  4. Have colleague gather supplies & contact HCP
  5. Put client in semi-fowlers posistion
  6. Prepare client for surgery
A
  1. Stay calm & stay with client
  2. Put client in semi-fowlers posistion
  3. Check VS
  4. Have colleague gather supplies & contact HCP
  5. Cover intestine with sterile moist gauze
  6. Prepare client for surgery
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14
Q

Postop cholecystectomy. Which should be immediately reported to HCP.

  1. Client can’t void 5 hrs postop
  2. Reports shoulder pain
  3. Upper right quadrant pain
  4. Output doesn’t = Input for first few hours
A

Upper right Quad pain = Possible hemorrhage or bile leak.

Right shoulder pain = unaborbed CO² , place in Sims to correct

Voiding will return in 6 hrs

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15
Q

Older adult puts 17g of polyethylene glycol in coffee everyday. Which assessment is nurse most likely to perform first.

  1. Assess for dehydration or electrolyte imbalance
  2. Assess S/S OD and call Poison control
  3. Ask to describe frequency and consistency of BM
  4. Ask client what they understand about purpose of the medication.
A
  1. Ask to describe frequency and consistency of BM

17 g daily is a normal dose to relieve chronic Constipation

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16
Q

2 days post op Laparotomysurgical (incisioninto theabdominalcavity, for diagnosis or in preparation for surgery.) Which is an immediate call HCP

  1. Abdominal distention or rigidity
  2. Displacement of NG tube
  3. Absent/ hypoactive bowel sounds
  4. N/ occasional V
A
  1. Abdominal distention or rigidity

S/S of hemorrhage or peritonitis. May also signal need of meds to stimulate peristalsis.

Absent bowel sounds normal 24 - 48 hrs posy op

17
Q

Recently admitted for severe diverticulitis. Appropriate for a UAP

  1. Have unit secretary call radiology & schedule barium enemas
  2. LPN give Laxatives PRN
  3. Nursing studen ambulation in hallway
  4. UAP to save stool specimen for Occult Blood
A
  1. UAP to save stool specimen for Occult Blood

Barium enemas Contradicted due to perforation

Laxatives & ambulation stimulate intestinal motility and are Contradicted in initial phase of treatment

18
Q

Colostomy care. Put in order

  1. Fit pouch snugly around stoma
  2. Assess thr color& appearance of stoma
  3. Wash skin with mild soap & rinse
  4. Apply a skin barrier to protect peristomal skin
  5. Dry skin carefully
  6. Don gloves and remove old patch
A
  1. Don gloves and remove old patch
  2. Assess thr color& appearance of stoma
  3. Wash skin with mild soap & rinse
  4. Dry skin carefully
  5. Apply a skin barrier to protect peristomal skin
  6. Fit pouch snugly around stoma
19
Q

Undernurished are at risk for refeeding syndrome when nourishment is first given. Priority nursing assessment.

  1. Monitor peripheral edema, crackles, jugular vein distention
  2. Monitor for decreased bowel sounds, nausea, bloating, distention
  3. Observe for signs of secret purging and ingestion of water to increase weight
  4. Assess for alternating Constipation & Diarrhea and pale clay-colored stools
A
  1. Monitor peripheral edema, crackles, jugular vein distention

Refeeding syndrome occurs when aggressive & rapid feeding results in fluid retention & HF. Monitor Phosphorus carefully

Purgingn& water injestion in eating disorder

20
Q

Advanced cirrhosis: Ascites, peripheral edema lower extremities, N/V, dyspnea due to pressure on diaphragm. Best indicator for tracking fluid retention

  1. Ausculate lungs daily
  2. Measure abdominal growth AM
  3. Perform daily weight checks with same scale & clothes
  4. Check extremities for pitting edema
A

Daily weight- best indicator of fluid volume

Other answers are correct too

21
Q

Cholecystectomy T tube in place for drainage. Which action requires immediate intervention

1.Maintain client in semi-fowlers
2. Check amount, color, & consistency of drainage
3. Gently aspirate drainage from tube
4. Inspect skin around tube for redness

A
  1. Gently aspirate drainage from tube

Tube not to be clamped, irritated, aspirated without HCP approval

22
Q

Portal HTN & hepatic Encephalopathy secondary to liver disease is being treated with lactulose. What lab to check to see if Lactulose is working

A

Ammonia

NCLEX: Prioritization, Delegation, And Assignment 5th Edition (26 decks)

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