GI + GU + Electrolytes Flashcards
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?
- Passes a normal brown stool
- Passed a stool mixed with blood
- Stopped crying
- Vomited a third time
- 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.
The nurse assesses a pediatric client who was diagnosed with diarrhea caused by Escherichia coli. The nurse is most concerned with which finding?
- Blood streaked stools
- Client drank fruit juice
- Dry mucous membranes
- Petechaie noted on trunk
- 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)
Foods to avoid for Celiac disease patients - BROW
Barley, Rye, Oats, Wheat
Nursing interventions related to stress incontinence
Training to void every 2 hours - bladder training
Kegel exercises (Pelvic floor exercies)
Lifestyle changes (Wt loss, less caffeine, less smoke)
Incontinence products (pads)
What is the highest priority when teaching a client newly diagnosed with stress incontinence?
- Kegel exercises (Pelvic floor exercises)
- Importance of voiding every 2 hrs
- Minimizing caffeine and alcohol
- Use of incontinence pads
- 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).
Diverticulitis prevention teaching, SATA:
- Dink plenty of fluids
- Exercise regularly
- Follow a low-residue diet
- Include whole grains, fruits, and vegetables
- Increase intake of red meat
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)
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.
- Calcium
- Fiber
- Iron
- Vitamin D
- Vitamin K
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).
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?
- Crackers an cheddar cheese
- Hard-boiled egg with tomatoes
- Steamed fish and potatoes
- Tortilla chips with avocado dip
- 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)
A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?
- Assess the client’s vital signs
- Check the client’s blood glucose
- Report the findings to the health care provider
- Slow down the rate of infusion
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
Dumping syndrome - risks, signs and symptoms
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.
Arteriovenous fistula - What is it? What is its purpose? What are some common findings with AV fistulas and complications?
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.
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.
- Assess for abd distention and constipation
- Contact the HCP
- Examine catheter for kinks and obstruction
- Flush tubing with 100 mL of dialysate
- Place client in a side-lying position
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).
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.
- Flank pain radiating to groin
- Ate high protein food before pain started
- Low fever with chills
- Pain at unbilicus
- RUQ pain radiating to right shoulder
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).
Prostatectomy - Post op findings (Blood clot) normal vs abnormal
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.
The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia?
- Elevate the head of bed
- Avoid caffeine and tobacoo
- Small, frequent, low fat meals
- Provide a girdle to reduce hernia
- Teach client to avoid lifting or straining
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)
What type of collection is needed for a creatinine clearance measurement?
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.
A client has been on a vegan diet for several years,which statement indicates potentialnutitional deficiency?
- I have visual disturbance while driving
- I have trouble falling asleep in the last few months
- Scaly patches of skin are developing on my elbows and knees
- Sometimes my hands and feet get a tingling sensation
- 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
After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority?
- Apply anti-embolism stockings
- Assist with early ambulation
- Offer stool softeners
- Provide low fat foods
- 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).
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
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.
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.
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
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: 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
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
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.
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: 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.
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.
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.
