GI + GU + Electrolytes

Question 1

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is most important?

1. Passes a normal brown stool
2. Passed a stool mixed with blood
3. Stopped crying
4. Vomited a third time

Answer 1

1. Passes a normal brown stool

Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery.

Question 2

The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding?

1. Blood streaked stools
2. Client drank fruit juice
3. Dry mucous membranes
4. Petechaie noted on trunk

Answer 2

4. Petechaie noted on trunk

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and needs further assessment.

Blood streaked stools is a common finding for E coli diarrhea. (Option 1)

Fruit juices are discouraged in acute diarrhea b/cthey have high sugar and low electolyte count. (Option 2)

Dry mucous membranes are a sign of dehydration, a common complication of any persistent diarrhea. (Option 3)

Question 3

Foods to avoid for Celiac disease patients - BROW

Answer 3

Barley, Rye, Oats, Wheat

Question 4

Nursing interventions related to stress incontinence

Answer 4

Training to void every 2 hours - bladder training

Kegel exercises (Pelvic floor exercies)

Lifestyle changes (Wt loss, less caffeine, less smoke)

Incontinence products (pads)

Question 5

What is the highest priority when teaching a client newly diagnosed with stress incontinence?

1. Kegel exercises (Pelvic floor exercises)
2. Importance of voiding every 2 hrs
3. Minimizing caffeine and alcohol
4. Use of incontinence pads

Answer 5

2. Importance of voiding every 2 hrs

The highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and urinary tract infections through bladder training. Teaching the client to empty the bladder every 2 hours when awake and every 4 hours at night reduces these risks (Option 2).

Question 6

Diverticulitis prevention teaching, SATA:

1. Dink plenty of fluids
2. Exercise regularly
3. Follow a low-residue diet
4. Include whole grains, fruits, and vegetables
5. Increase intake of red meat

Answer 6

A: 1, 2, 4

Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula).

These may be asymptomatic.

However, complications of diverticulitisinclude abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis.

The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure.

Measures to prevent constipation includediet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. (Options 1, 2, 4)

Question 7

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow’s milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply.

1. Calcium
2. Fiber
3. Iron
4. Vitamin D
5. Vitamin K

Answer 7

A: 1, 4

Calcium and vitamin D are nutrients in cow’s milk that are essential for proper bone development in children and adolescents (Options 1 and 4).

Question 8

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client?

1. Crackers an cheddar cheese
2. Hard-boiled egg with tomatoes
3. Steamed fish and potatoes
4. Tortilla chips with avocado dip

Answer 8

3. Steamed fish and potatoes

Weight loss are common in pts on antidepressants. We want to encourage a diet high in calories and protein to promote adequate nutrition and weight gain.

Foods that are protein and/or calorie dense include:

Whole milk and dairy products (eg, milkshakes), fruit smoothies
Granola, muffins, biscuits
Potatoes with sour cream and butter
Meat, fish, eggs, dried beans, almond butter
Pasta/rice dishes with cream sauce

Since the client is on phenelzine (MAOI), they must avoid tyramine foods such as cheese and avocados (Option 1 and 4).

Eggs are high in protein but low in calories (Option 2)

Question 9

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?

1. Assess the client’s vital signs
2. Check the client’s blood glucose
3. Report the findings to the health care provider
4. Slow down the rate of infusion

Answer 9

A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision.

The development of hyperglycemia is related to the following:

Excessive dextrose infusion
A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones
High infusion rate
Administration of medications such as steroids
Infection

Question 10

Dumping syndrome - risks, signs and symptoms

Answer 10

Risks: Gastrectomy

After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine.

This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. Similar to a client who has hypoglycemia.

Question 11

Arteriovenous fistula - What is it? What is its purpose? What are some common findings with AV fistulas and complications?

Answer 11

An arteriovenous fistula isa surgical connection of an artery with a veincreated to provide vascular access for hemodialysis therapy in clients with kidney disease.

A palpable thrill (vibration) over the fistula or an auscultated bruit (blowing or swooshing sound caused by turbulent blood flow) indicates a patent fistula.

Absence of the thrill or bruit can indicate potential clot formation in the fistula. Client reports of numbness or tingling as well as decreased capillary refill can also signal potential clotting.

Question 12

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.

1. Assess for abd distention and constipation
2. Contact the HCP
3. Examine catheter for kinks and obstruction
4. Flush tubing with 100 mL of dialysate
5. Place client in a side-lying position

Answer 12

A: 1, 3, 5

Insufficient outflow results most often from constipation when distended intestines block the catheter’s holes. Admin stool softener if needed (Option 1).
The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation (Options 3 and 5).

Question 13

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.

1. Flank pain radiating to groin
2. Ate high protein food before pain started
3. Low fever with chills
4. Pain at unbilicus
5. RUQ pain radiating to right shoulder

Answer 13

Symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula (Option 5).
Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia (Option 3).

Question 14

Prostatectomy - Post op findings (Blood clot) normal vs abnormal

Answer 14

For up to 36 hours after surgery, small blood clots may occur, although they should not impair the urine stream.

Consistent passage of clots after this time could indicate a postoperative complication.

Signs of such complications (eg, reduced urine stream, persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment.

Question 15

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia?

1. Elevate the head of bed
2. Avoid caffeine and tobacoo
3. Small, frequent, low fat meals
4. Provide a girdle to reduce hernia
5. Teach client to avoid lifting or straining

Answer 15

A: 1, 2, 3, 5

Nursing interventions to prevent hiatal hernias are similar to those used for gastroesophageal reflux disease (GERD), and they focus on decreasing intraabdominal pressure.

Elevate head of bed (>= 30 degrees) to minimize food from coming up into esophagus. (Option 1)
Caffeine, fatty foods, tobacco increases esophageal pressure - avoid them. (Options 2, 3)

Lifting or straining also increase esophageal pressure so avoid that(Option 4, 5). Girdle (shape wear around abdomen)

Question 16

What type of collection is needed for a creatinine clearance measurement?

Answer 16

A 24-hour urine collection is needed for the test.
When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24 hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container.

Question 17

A client has been on a vegan diet for several years,which statement indicates potentialnutitional deficiency?

1. I have visual disturbance while driving
2. I have trouble falling asleep in the last few months
3. Scaly patches of skin are developing on my elbows and knees
4. Sometimes my hands and feet get a tingling sensation

Answer 17

4. Sometimes my hands and feet get a tingling sensation

Vegan diet = plant based foods, omitting animal proteins.

Clients on vegan diet are at risk of developing vitamin B12 deficency.

Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain.

These include peripheral neuropathy (tingling, numbness), neuromuscular impairment (gait problems, poor balance), memory loss/ dementia

Question 18

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?

1. Apply anti-embolism stockings
2. Assist with early ambulation
3. Offer stool softeners
4. Provide low fat foods

Answer 18

2. Assist with early ambulation

The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery (Option 2).

Whenever the procedure involves laprascopes, it will have CO2 in it.CO2 can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. This is an expected finding.

Early ambulation not only improves breathing but also decreases the risk of thromboembolism(Option1) and stimulates peristalsis (Option 3).

Question 19

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit?

A. Bowel sounds of 14 per minute

B. High-pitched bowel sounds at a rate of 4 per minute

C. Bowel sounds greater than 60 per minute

D. Low-pitched bowel sounds at a rate of 30 per minute

Answer 19

B. High-pitched bowel sounds at a rate of 4 per minute

Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult.

Question 20

The nurse is caring for a client with acute pancreatitis who is receiving total parenteral nutrition (TPN) for three days. After reviewing the client’s laboratory data, the nurse should take which action?

Day one: Glucose = 168 mg/dL OR 9.3 mmol/L
Day two: Glucose = 189 mg/dL OR 10.5 mmol/L
Day three: Glucose = 221 mg/dL OR 12.3 mmol/L

A. Reduce the infusion rate of the TPN.

B. Obtain a prescription for sliding scale insulin.

C. Assess for signs and symptoms of hyperglycemia.

D. Pause the infusion for two hours and then reassess blood glucose.

Answer 20

B. Obtain a prescription for sliding scale insulin

The client’s BG is elevated, so the nurse should act to maintain normal BG levels.
The blood glucose target for a client receiving TPN is less than 180 mg/dL OR 10 mmol/L

A sliding scale insulin + insulin added to the TPN to maintain normal BG

Question 21

The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL. What does the nurse suspect could be the underlying cause of this electrolyte abnormality?

Select all that apply.

A. Renal failure

B. Alcoholism

C. Anorexia

D. Diarrhea

E. Hypothyroidism

Answer 21

Answer: A, E

Renal failure reduces magnesium filtered through kidneys so increases serum magnesium

Hypothyroidism increases magnesium

Alcoholism is a risk factor for hypomagnesemia, not hypermagnesemia

Question 22

The nurse is caring for a patient who has just returned from an intravenous urography procedure. Which of the following nursing interventions is most important at this time?

A. Assess the venipuncture site for redness

B. Monitor urinary output

C. Instruct the client to remain motionless

D. Encourage the patient to drink at least 1 L of fluid

Answer 22

D. Encourage the patient to drink at least 1 L of fluid

The dye used during intravenous urography is sometimes nephrotoxic. Thus patients should be encouraged to increase fluids unless contraindicated.

Question 23

Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction?

Select all that apply.

A. Draw up 30 mL of saline solution into the syringe.

B. Unclamp the suction tubing near the connection site to instill solution.

C. Place the tip of the syringe in the tube to gently insert saline solution.

D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.

E. After instilling the irrigant, hold the end of the NG tube over an irrigation tray.

F. Observe for return of NG drainage into an available container.

Answer 23

Answer: A, C, E, F

A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline (or the amount indicated on the order) into the syringe.

C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution.

E and F: After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container.

Question 24

The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take?

A. Administer prophylactic antibiotics.

B. Teach the client intermittent self-catheterization.

C. Have the client void on a timed schedule.

D. Provide caffeinated beverages with meals.

Answer 24

C. Have the client void on a timed schedule

The best non-invasive way to treat urge incontinence is to train the bladder to void on a timed schedule.

Timed voiding enables an individual to gradually increase the amount of urine they may hold without an abrupt urge to go to the bathroom.

The goal is also to prolong the time interval between urinating - up to a minimum of three or more hours.

Question 25

The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take?

A. Administer prophylactic antibiotics.

B. Teach the client intermittent self-catheterization.

C. Have the client void on a timed schedule.

D. Provide caffeinated beverages with meals.

Answer 25

C. Have the client void on a timed schedule

The best non-invasive way to treat urge incontinence is to train the bladder to void on a timed schedule.

Timed voiding enables an individual to gradually increase the amount of urine they may hold without an abrupt urge to go to the bathroom.

The goal is also to prolong the time interval between urinating - up to a minimum of three or more hours.

Question 26

Hypokalemia on the ECG, how will it present?

Answer 26

A. U wave and a flat T wave

Low potassium affects the heart’s ability to repolarize, which is reflected in an EKG with a flat T wave and, occasionally, the presence of a U wave.

Question 27

The nurse is providing dietary education to a client with renal failure who is receiving hemodialysis. The nurse determines that the client understands these dietary modifications and there is no need for further teaching if the client selects which items from the dietary menu?

A. Blueberries, cream of wheat, coffee

B. Bacon, banana, orange juice

C. Sausage, eggs, cantaloupe melon, tomato juice

D. Cured pork, grits, kiwi, orange juice

Answer 27

A. Blueberries, cream of wheat, coffee

B, C, D all contain high levels of salt (Sodium, potassium, phosphorus)

Question 28

Which of the following clients is at greatest risk for developing malnutrition?

A. A 72-year-old woman in a nursing home

B. An 81-year-old widow who lives alone

C. A 65-year-old with poor dentition who is married

D. A 79-year-old widower who receives food from ‘Meals on Wheels’

Answer 28

B. An 81-year-old widow who lives alone

This client has two risk factors of developing malnutrition: Elderly, living alone.

All of the other clients are under the supervision of others (A, C) , or receiving food through subscription (D: Meals on wheels)

Question 29

The nurse is discharging a client with a new sigmoid colostomy. Which statement from the client indicates a need for further teaching?

A. “I will call my doctor immediately if my stoma becomes bluish.”

B. “I can eat what I used to eat when I go back home.”

C. “I need to wear a pouch over my stoma.”

D. “I need to irrigate my colostomy every week with tap water.”

Answer 29

D. “I need to irrigate my colostomy every week with tap water.”

The colostomy should be washed daily with warm water to promote daily bowel movement.

A: blue discolorloration of stoma = low perfusion to site, need to notify HCP

B: The client can go back to normal diet once discharged and stoma is in good health

C: The pouch is over the stoma to collect feces

Question 30

The nurse is discharging a client with a new sigmoid colostomy. Which statement from the client indicates a need for further teaching?

A. “I will call my doctor immediately if my stoma becomes bluish.”

B. “I can eat what I used to eat when I go back home.”

C. “I need to wear a pouch over my stoma.”

D. “I need to irrigate my colostomy every week with tap water.”

Answer 30

D. “I need to irrigate my colostomy every week with tap water.”

The colostomy should be washed daily with warm water to promote daily bowel movement.

A: blue discolorloration of stoma = low perfusion to site, need to notify HCP

B: The client can go back to normal diet once discharged and stoma is in good health

C: The pouch is over the stoma to collect feces

Question 31

The nurse is taking care of a client with encopresis. Which of the following statements correctly describes encopresis?

A. Infrequent and hard to pass stools lasting greater than two weeks.

B. Voluntary or involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.

C. Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.

D. Inability to pass stool due to fecal impaction.

Answer 31

B: (???) What is voluntary incontinence???

The correct answer should be C - Involuntary fecal incontinence in children over the age of 4 who were previously toilet trained.

Question 32

A patient presents with enlarged tonsillar nodes. Acutely infected nodes would be:

A. Firm but movable and tender

B. Hard and nontender

C. Fixed and soft

D. Irregular and hard

Answer 32

A. Firm but movable and tender

Infected lymph nodes are usually tender.

Question 33

The student nurse is demonstrating competency for an indwelling foley catheter insertion on a female patient. Of the following actions, which would the experienced nurse who is observing recognize as a break in sterility due to contamination of the sterile field?

A. The student nurse applies sterile gloves, then removes the fenestrated drape from the sterile kit and places it over the patient.

B. The student opens the antiseptic swabs, applies sterile gloves, then cleans the patient.

C. The patient’s labia closes over the catheter during insertion.

D. After inserting the catheter and noting the absence of urine, the nursing student determines the catheter has accidentally been placed in the patient’s vagina.

Answer 33

B. The student opens the antiseptic swabs, applies sterile gloves, then cleans the patient.

The student broke sterile field by opening up the antiseptic swabs first. The swabs are sterile in the foley tray. The student should put on the gloves first before opening up the swabs.

Question 34

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration?

1. Atenolol
2. Calcium acetate
3. Insulin lispro
4. Vitamin E

Answer 34

1. Atenolol

Fluid is removed during dialysis, which may cause hypotension. Typically, antihypertensives are held before dialysis to prevent hypotension. In addition, some medications are dialyzed out of the client’s system and should therefore be held until after dialysis. Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin.

Question 35

Primary cause of bladder cancer

Answer 35

Cigarette smoking, tobacco use

Question 36

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions?

1. Having sex will make the infection worse
2. I enjoy tea, so I will drink more to stay hydrated
3. I should take ciprofloxacin until I feel better
4. I should take docusate to prevent straining

Answer 36

4. I should take docusate to prevent straining

Take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the prostate, causing pain (Option 4).

Hydrate with clear fluids, avoid coffee, tea and other caffeinated drinks due to diuretic and stimulant properties, may worsen symtpoms (Option 2)

Complete full course of abx to ensure infection resolution (Option 3)

Sexual intercourse, masturbation reduces discomfort (Option 1)

Question 36

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions?

1. Having sex will make the infection worse
2. I enjoy tea, so I will drink more to stay hydrated
3. I should take ciprofloxacin until I feel better
4. I should take docusate to prevent straining

Answer 36

4. I should take docusate to prevent straining

Take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the prostate, causing pain (Option 4).

Question 37

A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention?

1. Admin IV 50% dextrose and regular insulin
2. Admin IV furosemide
3. Admin oral sodium polystyrene sulfonate
4. Prepare the client for hemodialysis catheter placement

Answer 37

1. Admin IV 50% dextrose and regular insulin

All of the interventions are appropriate to lower the potassium in the client.
However, The IV 50% dextrose and regular insulin is the fastest way to lower the hyperkalemia (Shifting the potassium from extracellular fluid to intracellular fluid). Therefore it is the priority intervention.

The dextrose is to prevent for hypoglycemia, while the insulin shifts K+ back into cells.

Question 38

Which client statement indicates further teaching is required taking Oxybutynin?

1. I am looking forward to our summer vacation at the beach
2. I plan to eat more fruits and vegetables to prevent constipation
3. I should not drive until I know how this drug affects me
4. I will drink at least 6-8 glasses of water daily

Answer 38

1. I am looking forward to our summer vacation at the beach

Oxybutynin is a anticholinergic med used to treat overactive bladder.
With an anticholinergic med, it decreases the mucus secretion in the body (No see, no pee, No spit, no shit).
This also includes the sweat glands.

Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity (Option 1).

Question 39

A client came back from a kidney biopsy. Which intervention should be included in the post op care plan?

1. Compare pre and post procedure BUN and creatinine levels
2. Insert and maintain patency of an indwelling catheter.
3. Maintain prone position for at least 30 mins
4. Monitor vital signs every 15 mins for the first hr.

Answer 39

4. Monitor vital signs every 15 mins for the first hr.

The nurse should monitor vital signs post kidney biopsy because the kidney is an extensive vasculature (Similar to liver).

Therefore, bleeding from the biopsy site is a major complication.

So the nurse should monior vital signs Q15 mins for tachycardia, tachypnea, hypotension that may indicate blood loss. As well as the dressing site for bleeds.

Before the procedure, the client must give informed consent and discontinue all anticoagulants (eg, heparin, warfarin, rivaroxaban) and antiplatelet agents (eg, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) for at least one week. The client should be typed and crossmatched for blood (although the need for a transfusion is rare). Blood pressure should be well-controlled.