GI (LOWER): NCLEX REVIEW 2

Question 1

S/S of Small Intestine Obstruction (3)

Answer 1

1. Projectile vomiting
2. Rapid onset of dehydration
3. INCREASE bowel sounds (high pitched and tinkling)

Question 2

Bowel Obstruction: Physican orders

1. Ambulation to promote peristalsis
2. Insert NG tube
3. Admin IV Ringer’s lactate
4. start infusion of hyperalimentation fluid

Client presents n/v crampy abd pain

list steps in priority

Answer 2

1. Ambulation to promote peristalsis
2. Admin IV Ringer’s lactate (Isotonic)
3. Insert NG tube (feeding and decompression)
4. start infusion of hyperalimentation fluid

Question 3

enteral hyperalimentation

Answer 3

the use of a gastrointestinal tube.

Question 4

Decompression for intestinal obstruction

How to determine effectiveness? (2)

Answer 4

Intestinal fluid and gas have been removed

Question 5

After insertion of nasoenteric tube pt should be in what position?

Answer 5

1. Right side to assist tube thur the pyloric sphincter
2. then roll side to side to move tube through intestinal loops

Question 6

Nasoduodenal tube how to confirm placement?

Answer 6

x-ray with the use of a contrast dye used to verify placement

Question 7

If nasoenteric tube is patent and draining but client is uncomfortable assess for?

Answer 7

Rigid abd, peritonitis

Question 8

When calculating Intake and output

Include:

Answer 8

Intake:

• IV,
• oral including tube feeding

Output:

• 1000 ml insensible fluid loss
• urine
• tube drainage

Question 9

Ileostomy

Answer 9

a surgical operation in which a piece of the ileum is diverted to an artificial opening in the abdominal wall.

an opening so formed.

Question 10

Milk of Magnesia (magnesium hydroxide)

What does it do?

Answer 10

Magnesium is a naturally occurring mineral. Magnesium is important for many systems in the body especially the muscles and nerves. Magnesium hydroxide also reduces stomach acid, and increases water in the intestines which may induce defecation.

Magnesium hydroxide is used as a laxative to relieve occasional constipation (irregularity) and as an antacid to relieve indigestion, sour stomach, and heartburn.

Question 11

Antacids: What do they do?

Answer 11

Antacids neutralise the acid made by your stomach. They are commonly used in conditions where it is helpful to neutralise the acid made in the stomach. For example, for acid reflux which causes heartburn. Most people who take antacids do not develop any side-effects.

do NOT take them with food

Take them before you eat

You may have side effects from taking these medicines. Antacids are made with three basic ingredients. If you have problems, try another brand.

Brands with magnesium may cause diarrhea.
Brands with calcium or aluminum may cause constipation.
Rarely, brands with calcium may cause kidney stones or other problems.
If you take large amounts of antacids that contain aluminum, you may be at risk for calcium loss, which can lead to weak bones (osteoporosis).

Question 12

Ileostomy Pouch change how often?

Answer 12

Every 4-7 days but if leaking change immediately

Question 13

Client pre-op prep at 2 weeks

1. When to stop drugs that interfere with clotting eg aspirin or ibuprofen?
2. What kind of diet?
3. Increase or decrease fluid intake?

Answer 13

1. 2 weeks
2. High-fiber diet
3. Increase fluids

Question 14

Immediately post-op to create ileostomy, highest priority

Answer 14

Maintain fluid and electrolyte balance

Question 15

A nurse at discharge should teach client with ileostomy pouch to call physician when? (3)

How much fluid should nurse instruct client to intake daily?

Answer 15

1. Any sudden decrease or watery drainage with no stool
2. Sudden onset of severe abd pain/cramps
3. Vomiting

COULD INDICATE AN OBSTRUCTION and oral intake is avoided with obstruction is suspected

3000 ml/daily at least

Question 16

TPN Administration

Total Parenteral Nutrition (TPN)

1. Access?
2. Tonicity
3. Schedule
4. Auscultate for bowel sounds before adm?
5. TPN mixture is based on?
6. Why is a fat emulsion soln administered?
7. How to handle TPN (precautions)
8. What do you do if there is drainage at central line insertion site?
9. Is a fever a the first few days after TPN therapy alarming?

Answer 16

1. CENTRAL VENOUS ACCESS( possibly via subclavian vein)
2. Hypertonic dextrose soln
3. Once daily
4. NO NEED TO AUSCULTATE FOR Bowel Sounds before admin
5. TPN mixture based on client’s current electrolyte and fluid balance
6. Use Aseptic technique: aseptic - also known as clean technique (such as washing hands, using clean [not sterile] gloves)
7. Provides additional calories and essential fatty acids
8. Culture
9. Yes, may indicate infection

Question 17

TPN ADMIN

TPN

1. When inserting or removing CVAD ask client to perform the Valsalva maneuver…what is this?
2. TPN is not used to meet client’s hydration needs? T/F
3. Which can develop due to TPN? Metabolic acidosis or ketoacidosis.

Answer 17

1. CVAD= Central Venous Access Device, ask pt to take deep breath and hold it. This increases central venous pressure and prevents air embolism. Trendelenburg is preferred postion during insertion and removal
2. TRUE, TPN only meets nutritional needs
3. Ketoacidosis:

Diabetic ketoacidosis is a life-threatening problem that affects people with diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead.

When fat breaks down, waste products called ketones build up in the body.

Question 18

TPN ADMIN

TPN

1. Complications: Infection, air embolism and/or PNEUMOTHORAX if pneumothorax is suspected do what? (4) list by priority

Answer 18

1. Notify physician
2. Position rolled towel under client’s back parallel to spine
3. Culture site
4. Change dressing according

Question 19

Client uses sliding scale how does nurse determine how much insulin to administer?

Joslin Diabetes

Answer 19

Sliding Scale

A sliding scale varies the dose of insulin based on blood glucose level. The higher your blood glucose the more insulin you take via glucose meter reading/result before meal.

The Sliding Scale method is more precise than fixed dose insulin in that it takes account of the fact that people’s blood glucose is not always in the normal range before meals. Sliding Scale requires a bit more “patient investment” than Fixed Dose, as you might imagine.

Whereas in a fixed-dose scheme, while strongly recommended it is not absolutely necessary to take a blood glucose reading before giving an injection. In order to know how much insulin to take via a sliding scale, you have to check. Like the fixed dose the sliding scale approach assumes that a consistent amount of carbohydrate is eaten at meals.

This method works well for people who want more control over their blood glucose, are willing to do the requisite monitoring, and are committed to a structured meal plan.