TEST 6: The Client with Lower Gastrointestinal Tract Health Problems

Question 1

The Client with Cancer of the Colon
1. Which of the following guidelines reflects the current American and Canadian Cancer
Societies’ recommendations for screening for colon cancer in individuals who are not at high risk?
1. Annual digital rectal examination should begin at age 40.
2. Annual fecal testing for occult blood should begin at age 50.
3. Individuals should obtain a baseline barium enema at age 40.
4. Individuals should obtain a baseline colonoscopy at age 45.

Answer 1

The Client with Cancer of the Colon
1. 2. Annual fecal testing for occult blood should begin at age 50. Annual digital rectal
examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline
barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and
colonoscopies are not performed on individuals in their 40s unless they experience signs or
symptoms that indicate the need for such diagnostic testing, or are considered to be at high risk.
CN: Health promotion and maintenance; CL: Apply

Question 2

2. A client refuses to look at or care for her colostomy. Which of the following statements by the
   nurse would be most appropriate?
3. “It has been 4 days since your surgery, and you will soon be discharged. You have to learn to
   care for your colostomy before you leave the hospital.”
4. “I think we will need to teach your husband to care for your colostomy if you are not going to
   be able to do it.”
5. “I understand how you are feeling. It is important for you to feel attractive and you think having
   a colostomy changes your attractiveness.”
6. “I can see that you are upset. Would you like to share your concerns with me?”

Answer 2

2. 4. It is important for the nurse to recognize that individuals go through a grieving process when
      adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to
      share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to
      care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy
      by implying her husband will have to provide the care if she does not. It is not possible for the nurse
      to understand what the client is feeling.
      CN: Psychosocial adaptation; CL: Synthesize

Question 3

3. Which of the following is a potential risk factor for the development of colon cancer?
4. Chronic constipation.
5. Long-term use of laxatives.
6. History of smoking.
7. History of inflammatory bowel disease.

Answer 3

3. 4. A history of inflammatory bowel disease is a risk factor for colon cancer. Other risk factors
      include age (older than 40 years), history of familial polyposis, colorectal polyps, and high-fat or
      low-fiber diet.
      CN: Reduction of risk potential; CL: Analyze

Question 4

4. The nurse is conducting a community presentation on the early detection of colon cancer.
   Which of the following should the nurse encourage members of the audience to report to their health
   care providers? Select all that apply.
5. Fatigue.
6. Unexplained weight loss with adequate nutritional intake.
7. Rectal bleeding.
8. Bowel changes.
9. Positive fecal occult blood testing.

Answer 4

4. 1, 2, 3, 4, 5. Colorectal cancer may be asymptomatic, or symptoms vary according to the
   location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia,
   even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer.
   Fecal occult blood testing commonly reveals evidence of carcinoma when the client is otherwise
   asymptomatic.
   CN: Health promotion and maintenance; CL: Create

Question 5

5. A client with colon cancer is having a barium enema. The nurse should instruct the client to
   take which of the following after the procedure is completed?
6. Laxative.
7. Anticholinergic.
8. Antacid.
9. Demulcent

Answer 5

5. 1. After a barium enema, a laxative is ordinarily prescribed. This is done to promote
      elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction.
      Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion.
      Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.
      CN: Reduction of risk potential; CL: Synthesize

Question 6

6. A client has a nasogastric tube inserted at the time of abdominal perineal resection with
   permanent colostomy for colon cancer. This tube will most likely be removed when the client
   demonstrates:
7. Absence of nausea and vomiting.
8. Passage of mucus from the rectum.
9. Passage of flatus and feces from the colostomy.4. Absence of stomach drainage for 24 hours.

Answer 6

6. 3. A sign indicating that a client’s colostomy is open and ready to function is passage of feces
      and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed tostart taking fluids and food orally. Absence of bowel sounds would indicate that the tube should
      remain in place because peristalsis has not yet returned.

Question 7

7. The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of
   the following nursing interventions is most appropriate for this client in the postoperative period?
8. Maintain the client in a semi-Fowler’s position.
9. Assist the client with warm sitz baths.
10. Administer 30 mL of milk of magnesia to stimulate peristalsis.
11. Remove the ostomy pouch as needed so the stoma can be assessed.

Answer 7

7. 2. Appropriate nursing interventions after an abdominal-perineal resection with a colostomy
      include assisting the client with warm sitz baths three to four times a day to clean the perineal
      incision. The client will be more comfortable assuming a side-lying position because of the perineal
      incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity.
      Stool passage will begin as peristalsis returns. It is not necessary or desirable to change the ostomy
      pouch daily to assess the stoma. The ostomy pouch should be transparent to allow easy observation of
      the stoma and drainage.
      CN: Physiological adaptation; CL: Synthesize

Question 8

8. The nurse assesses the client’s stoma during the initial postoperative period. Which of the
   following observations should be reported immediately to the physician?
9. The stoma is slightly edematous.
10. The stoma is dark red to purple.
11. The stoma oozes a small amount of blood.
12. The stoma does not expel stool.

Answer 8

8. 2. A dark red to purple stoma indicates inadequate blood supply. Mild edema and slight oozing
      of blood are normal in the early postoperative period. The colostomy would typically not begin
      functioning until 2 to 4 days after surgery.
      CN: Physiological adaptation; CL: Analyze

Question 9

9. While changing the client’s colostomy bag and dressing, the nurse assesses that the client is
   ready to participate in self-care by noting which of the following?
10. The client asks what time the doctor will visit that day.
11. The client asks about the supplies used during the dressing change.
12. The client talks about the news on the television.
13. The client is upsets about the way the night nurse changed the dressing.

Answer 9

9. 2. A client who displays interest in the procedure and asks about supplies used for dressings
      may be ready to participate in self-care. Inquiring about the physician’s visit, discussing news events,
      and discussing a dressing change are behaviors that avoid the subject of the colostomy.
      CN: Basic care and comfort; CL: Analyze

Question 10

10. Which of the following skin preparations would be best to apply around the client's
colostomy?
1. Stomahesive.
2. Petroleum jelly.
3. Cornstarch.
4. Antiseptic cream.

Answer 10

10. 1. Stomahesive is effective for protecting the skin around a colostomy to keep the skin healthy
       and prevent skin irritation from stoma drainage. Petroleum jelly, cornstarch, and antiseptic creams do
       not protect the skin adequately and may prevent an adequate seal between the skin and the colostomy
       bag.
       CN: Basic care and comfort; CL: Apply

Question 11

11. A client is recovering from an abdominal-perineal resection. Which of the following
    measures would most effectively promote wound healing after the perineal drains have been
    removed?
12. Taking sitz baths.
13. Taking daily showers.
14. Applying warm, moist dressings to the area.
15. Applying a protected heating pad to the area.

Answer 11

11. 1. Sitz baths are an effective way to clean the operative area after an abdominal-perineal
       resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and
       cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be
       kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may
       promote wound contamination and delay healing. A heating pad applied to the area for longer than 20
       minutes may cause excessive vasodilation, leading to congestion and discomfort.
       CN: Physiological adaptation; CL: Synthesize

Question 12

11. A client is recovering from an abdominal-perineal resection. Which of the following
    measures would most effectively promote wound healing after the perineal drains have been
    removed?
12. Taking sitz baths.
13. Taking daily showers.
14. Applying warm, moist dressings to the area.
15. Applying a protected heating pad to the area.

Answer 12

12. 3. It is best to adjust the diet of a client with a colostomy in a manner that suits the client
       rather than trying special diets. Severe restriction of roughage is not recommended. The client is
       encouraged to drink 2 to 3 L of fluid per day. A high-fiber diet may produce loose stools.
       CN: Basic care and comfort; CL: Create

Question 13

13. Which of the following is an expected outcome for a client who is recovering from an
    abdominal-perineal resection with a colostomy? The client will:
14. Maintain a fluid intake of 3,000 mL/day.
15. Eliminate fiber from the diet.3. Limit physical activity to light exercise.
16. Accept that sexual activity will be diminished.

Answer 13

13. 1. An expected outcome is that the client will maintain a fluid intake of 3,000 mL/day unless
       contraindicated. There is no need to eliminate fiber from the diet; the client can eat whatever foods
       are desired, avoiding those that are bothersome. Physical activity does not need to be limited to light
       exercise. The client can resume normal activities as tolerated, usually within 6 to 8 weeks. The
       client’s sexual activity may be affected, but it does not need to be diminished.
       CN: Physiological adaptation; CL: Evaluate

Question 14

14. A client with colon cancer has developed ascites. The nurse should conduct a focused
    assessment for which of the following? Select all that apply.
15. Respiratory distress.
16. Bleeding.
17. Fluid and electrolyte imbalance.
18. Weight gain.
19. Infection.

Answer 14

14. 1, 3. Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift
    from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct
    consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in
    the intravascular space results in decreased oncotic pressure precipitating movement of fluid out of
    space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to
    remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.
    CN: Physiological adaptation; CL: Analyze

Question 15

The Client with Hemorrhoids
15. A 36-year-old female client has been diagnosed with hemorrhoids. Which of the following
factors in the client’s history would most likely be a primary cause of her hemorrhoids?
1. Her age.
2. Three vaginal delivery pregnancies.
3. Her job as a schoolteacher.
4. Varicosities in her legs.

Answer 15

The Client with Hemorrhoids
15. 2. Hemorrhoids are associated with prolonged sitting or standing, portal hypertension, chronic
constipation, and prolonged increased intra-abdominal pressure, as associated with pregnancy and
the strain of vaginal delivery. Her job as a schoolteacher does not require prolonged sitting or
standing. Age and leg varicosities are not related to the development of hemorrhoids.
CN: Reduction of risk potential; CL: Analyze

Question 16

16. Which position would be best for the client in the early postoperative period after a
hemorrhoidectomy?
1. High Fowler's.
2. Supine.
3. Side-lying.
4. Trendelenburg's.

Answer 16

16. 3. Positioning in the early postoperative phase should avoid stress and pressure on the
       operative site. The prone and side-lying positions are ideal from a comfort perspective. A high
       Fowler’s or supine position will place pressure on the operative site and is not recommended. There
       is no need for Trendelenburg’s position.
       CN: Physiological adaptation; CL: Synthesize

Question 17

17. The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at
    least 12 hours postoperatively to avoid inducing which of the following complications?
18. Hemorrhage.
19. Rectal spasm.
20. Urine retention.
21. Constipation.

Answer 17

17. 1. Applying heat during the immediate postoperative period may cause hemorrhage at the
       surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by
       reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help
       prevent constipation.
       CN: Physiological adaptation; CL: Apply

Question 18

18. The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The
    client has understood the teaching when the client states that it is most important to take a sitz bath:
19. First thing each morning.
20. As needed for discomfort.
21. After a bowel movement.
22. At bedtime.

Answer 18

18. 3. Adequate cleaning of the anal area is difficult but essential. After rectal surgery, sitz baths
       assist in this process, so the client should take a sitz bath after a bowel movement. Other times are
       dictated by client comfort.
       CN: Reduction of risk potential; CL: Evaluate

Question 19

The Client with Inflammatory Bowel Disease
19. A client has been placed on long-term sulfasalazine therapy for treatment of ulcerative colitis.
The nurse should encourage the client to eat which of the following foods to help avoid the nutrient
deficiencies that may develop as a result of this medication?
1. Citrus fruits.
2. Green, leafy vegetables.
3. Eggs.
4. Milk products.

Answer 19

The Client with Inflammatory Bowel Disease
19. 2. In long-term sulfasalazine therapy, the client may develop folic acid deficiency. The client
can take folic acid supplements, but the nurse should also encourage the client to increase the intake
of folic acid in his diet. Green, leafy vegetables are a good source of folic acid. Citrus fruits, eggs,
and milk products are not good sources of folic acid.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 20

20. The nurse is assigning clients for the evening shift. Which of the following clients are
    appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that
    apply.
21. A client with Crohn’s disease who is receiving total parenteral nutrition (TPN).
22. A client who underwent inguinal hernia repair surgery 3 hours ago.
23. A client with an intestinal obstruction who needs a Cantor tube inserted.
24. A client with diverticulitis who needs teaching about take-home medications.
25. A client who is experiencing an exacerbation of his ulcerative colitis.

Answer 20

20. 2, 5. The nurse should consider client needs and scope of practice when assigning staff to
    provide care. The client who is recovering from inguinal hernia repair surgery and the client who is
    experiencing an exacerbation of ulcerative colitis are appropriate clients to assign to a licensed
    practical nurse as the care they require falls within the scope of practice for a licensed practical
    nurse. It is not within the scope of practice for the licensed practical nurse to administer TPN, insert
    nasoenteric tubes, or provide client teaching related to medications.CN: Management of care; CL: Synthesize

Question 21

21. A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an
    exacerbation of the disease. Which of the following factors is most likely of greatest significance in
    causing an exacerbation of ulcerative colitis?
22. A demanding and stressful job.
23. Changing to a modified vegetarian diet.
24. Beginning a weight-training program.
25. Walking 2 miles (3.2 km) every day.

Answer 21

21. 1. Stressful and emotional events have been clearly linked to exacerbations of ulcerative
       colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian
       diet or an exercise program is an unlikely cause of the exacerbation.
       CN: Physiological adaptation; CL: Apply

Question 22

A client who is experiencing an exacerbation of ulcerative colitis is receiving IV fluids that are to be
infused at 125 mL/h. The IV tubing delivers 15 gtt/mL. How quickly should the nurse infuse the fluids
in drops per minute to infuse the fluids at the prescribed rate?
______________________ gtt/min.

Answer 22

22. 31 gtt/min
    To administer IV fluids at 125 mL/h using tubing that has a drip factor of 15 gtt/mL, the nurse
    should use the following formula:
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 23

23. When planning care for a client with ulcerative colitis who is experiencing an exacerbation
    of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed
    assistant? Select all that apply.
24. Assessing the client’s bowel sounds.
25. Providing skin care following bowel movements.
26. Evaluating the client’s response to antidiarrheal medications.
27. Maintaining intake and output records.
28. Obtaining the client’s weight.

Answer 23

23. 2, 4, 5. The nurse can delegate the following basic care activities to the unlicensed assistant:
    providing skin care following bowel movements, maintaining intake and output records, and obtaining
    the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to
    medication are registered nurse activities that cannot be delegated.
    CN: Management of care; CL: Synthesize

Question 24

24. Which goal for the client’s care should take priority during the first days of hospitalization for
    an exacerbation of ulcerative colitis?
25. Promoting self-care and independence.
26. Managing diarrhea.
27. Maintaining adequate nutrition.4. Promoting rest and comfort.

Answer 24

24. 2. Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing
       the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best
       achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic
       agents, bulk hydrophilic agents, or anti-inflammatory drugs.
       CN: Physiological adaptation; CL: Synthesize

Question 25

25. The client with ulcerative colitis is to be on bed rest with bathroom privileges. When
    evaluating the effectiveness of this level of activity, the nurse should determine if the client has:
26. Conserved energy.
27. Reduced intestinal peristalsis.
28. Obtained needed rest.
29. Minimized stress.

Answer 25

25. 2. Although modified bed rest does help conserve energy and promotes comfort, its primary
       purpose in this case is to help reduce the hypermotility of the colon. Remaining on bed rest does not
       by itself reduce stress, and if the client is having stress, the nurse can plan with the client to use
       strategies that will help the client manage the stress.
       CN: Physiological adaptation; CL: Evaluate

Question 26

26. A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting
    longer than 1 week. The nurse should assess the client for which of the following complications?
27. Heart failure.
28. Deep vein thrombosis.
29. Hypokalemia.
30. Hypocalcemia.

Answer 26

26. 3. Excessive diarrhea causes significant depletion of the body’s stores of sodium and
       potassium as well as fluid. The client should be closely monitored for hypokalemia and
       hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein
       thrombosis, or hypocalcemia.
       CN: Reduction of risk potential; CL: Analyze

Question 27

27. A client who has ulcerative colitis says to the nurse, “I can’t take this anymore; I’m constantly
    in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with
    this.” Based on these comments, the nurse should determine the client is experiencing:
28. Extreme fatigue.
29. Disturbed thought.
30. A sense of isolation.
31. Difficulty coping.

Answer 27

27. 4. It is not uncommon for clients with ulcerative colitis to become apprehensive and have
       difficulty coping with the frequency of stools and the presence of abdominal cramping. During these
       acute exacerbations, clients need emotional support and encouragement to verbalize their feelings
       about their chronic health concerns and assistance in developing effective coping methods. The client
       has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes.
       CN: Psychosocial adaptation; CL: Analyze

Question 28

28. A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the
    nurse why steroids are prescribed. The nurse should tell the client:
29. “Ulcerative colitis can be cured by the use of steroids.”
30. “Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”
31. “Long-term use of steroids will prolong periods of remission.”
32. “The side effects of steroids outweigh their benefits to clients with ulcerative colitis.”

Answer 28

28. 2. Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids
       do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging
       the remission and is not advocated. Clients should be assessed carefully for side effects related to
       steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverseeffects.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 29

29. A client who has ulcerative colitis has persistent diarrhea, and has lost 12 lb (5.4 kg) since
    the exacerbation of the disease. Which of the following will be most effective in helping the client
    meet nutritional needs?
30. Continuous enteral feedings.
31. Following a high-calorie, high-protein diet.
32. Total parenteral nutrition (TPN).
33. Eating six small meals a day.

Answer 29

29. 3. Food will be withheld from the client with severe symptoms of ulcerative colitis to rest the
       bowel. To maintain the client’s nutritional status, the client will be started on TPN. Enteral feedings
       or dividing the diet into six small meals does not allow the bowel to rest. A high-calorie, high-protein
       diet will worsen the client’s symptoms.
       CN: Physiological adaptation; CL: Apply

Question 30

30. A client with ulcerative colitis is to take sulfasalazine. Which of the following instructions
    should the nurse provide for the client about taking this medication at home? Select all that apply.
31. Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day.
32. Discontinue therapy if symptoms of acute intolerance develop and notify the health care
    provider.
33. Stop taking the medication if the urine turns orange-yellow.
34. Avoid activities that require alertness.
35. If dose is missed, skip and continue with the next dose.

Answer 30

30. 1, 2, 4. Sulfasalazine may cause dizziness, and the nurse should caution the client to avoid
driving or other activities that require alertness until response to medication is known. If symptoms of
acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the
client should discontinue therapy and notify the health care provider immediately. Fluid intake should
be sufficient to maintain a urine output of at least 1,200 to 1,500 mL daily to prevent crystalluria and
stone formation. The nurse can also inform the client that this medication may cause orange-yellow
discoloration of urine and skin, which is not significant and does not require the client to stop taking
the medication. The nurse should instruct the client to take missed doses as soon as remembered
unless it is almost time for the next dose.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 31

31. The physician prescribes sulfasalazine for the client with ulcerative colitis. Which instructionshould the nurse give the client about taking this medication?
32. Avoid taking it with food.
33. Take the total dose at bedtime.
34. Take it with a full glass (240 mL) of water.
35. Stop taking it if urine turns orange-yellow.

Answer 31

31. 3. Adequate fluid intake of at least eight glasses a day prevents crystalluria and stone
       formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best
       taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow
       color, but it is not necessary to stop the drug when this occurs.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 32

The nurse has a prescription to administer sulfasalazine 2 g. The medication is available in 500-mg
tablets. How many tablets should the nurse administer?
_______________ tablets.

Answer 32

x32. 4 tablets
To administer 2 g sulfasalazine, the nurse will need to administer four tablets. The following
formula is used to calculate the correct dosage:
The first step is to convert grams into milligrams:
Then,

1 g / 1000 mg = 2mg / X mg
X= 2000mg

2000mg /X tabs = 500 mg / tab
X= 4 Tabs

CN: Pharmacological and parenteral therapies; CL: Apply

Question 33

33. Which of the following diets would be most appropriate for the client with ulcerative
colitis?
1. High-calorie, low-protein.
2. High-protein, low-residue.
3. Low-fat, high-fiber.
4. Low-sodium, high-carbohydrate.

Answer 33

33. 2. Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie,
       low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and
       vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid
       excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.
       CN: Basic care and comfort; CL: Apply

Question 34

34. A client who has a history of Crohn’s disease is admitted to the hospital with fever, diarrhea,
    cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
35. Hyperalbuminemia.
36. Thrombocytopenia.
37. Hypokalemia.
38. Hypercalcemia.

Answer 34

34. 3. Hypokalemia is the most expected laboratory finding owing to the diarrhea.
       Hypoalbuminemia can also occur in Crohn’s disease; however, the client’s potassium level is of
       greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an
       expected development, but thrombocytopenia is not. Calcium levels are not affected.
       CN: Physiological adaptation; CL: Analyze

Question 35

35. A client with Crohn’s disease has concentrated urine; decreased urinary output; dry skin with
    decreased turgor; hypotension; and weak, thready pulses. The nurse should do which of the following
    first?
36. Encourage the client to drink at least 1,000 mL/day.
37. Provide parenteral rehydration therapy prescribed by the physician.
38. Turn and reposition every 2 hours.
39. Monitor vital signs every shift.

Answer 35

35. 2. Initially, the extracellular fluid (ECF) volume with isotonic IV fluids until adequatecirculating blood volume and renal perfusion are achieved. Vital signs should be monitored as
       parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day.
       Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but
       it is first necessary to rehydrate this client.
       CN: Physiological adaptation; CL: Synthesize

Question 36

36. The nurse is developing a plan of care for a client with Crohn’s disease who is receiving
    total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
    Select all that apply.
37. Monitoring vital signs once a shift.
38. Weighing the client daily.
39. Changing the central venous line dressing daily.
40. Monitoring the IV infusion rate hourly.
41. Taping all IV tubing connections securely.

Answer 36

36. 2, 4, 5. When caring for a client who is receiving TPN, the nurse should plan to weigh the
    client daily, monitor the IV fluid infusion rate hourly (even when using an IV fluid pump), and
    securely tape all IV tubing connections to prevent disconnections. Vital signs should be monitored at
    least every 4 hours to facilitate early detection of complications. It is recommended that the IV
    dressing be changed once or twice per week or when it becomes soiled, loose, or wet.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 37

37. Which of the following should be a priority focus of care for a client experiencing an
    exacerbation of Crohn’s disease?
38. Encouraging regular ambulation.
39. Promoting bowel rest.
40. Maintaining current weight.
41. Decreasing episodes of rectal bleeding.

Answer 37

37. 2. A priority goal of care during an acute exacerbation of Crohn’s disease is to promote bowel
       rest. This is accomplished through decreasing activity, encouraging rest, and initially placing client on
       nothing-by-mouth status while maintaining nutritional needs parenterally. Regular ambulation is
       important, but the priority is bowel rest. The client will probably lose some weight during the acute
       phase of the illness. Diarrhea is nonbloody in Crohn’s disease, and episodes of rectal bleeding are not
       expected.
       CN: Physiological adaptation; CL: Synthesize

Question 38

The Client with an Intestinal Obstruction
38. A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the
small intestine. The nurse should assess the client for which of the following? Select all that apply.
1. Projectile vomiting.
2. Significant abdominal distention.
3. Copious diarrhea.
4. Rapid onset of dehydration.
5. Increased bowel sounds.

Answer 38

The Client with an Intestinal Obstruction
38. 1, 4, 5. Signs and symptoms of intestinal obstructions in the small intestine may include
projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will
also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally
have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by
vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain,
and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and
significant abdominal distention.
CN: Physiological adaptation; CL: Analyze

Question 39

39. A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy
    abdominal pain. The physician has written the following prescriptions: for the client to be up ad lib,
    have narcotics for pain, and have a nasogastric tube inserted if needed, and for IV Ringer’s lactate and
    hyperalimentation fluids. The nurse should do the following in order of priority from first to last:
40. Assist with ambulation to promote peristalsis.
41. Insert a nasogastric tube.
42. Administer IV Ringer’s lactate.
43. Start an infusion of hyperalimentation fluids.

Answer 39

39.
1. Assist with ambulation to promote peristalsis.
2. Administer Ringer’s Lactate.
3. Insert a nasogastric tube.
4. Start an infusion of hyperalimentation fluids.
The nurse should first help the client ambulate to try to induce peristalsis; this may be effective
and require the least amount of invasive procedures. Next, the nurse should initiate IV fluid therapy tocorrect fluid and electrolyte imbalances (sodium and potassium) with Ringer’s Lactate to correct
interstitial fluid deficit. Nasogastric (NG) decompression of GI tract to reduce gastric secretions and
nasointestinal tubes may also be used as necessary. Lastly, hyperalimentation can be used to correct
protein deficiency from chronic obstruction, paralytic ileus, or infection.
CN: Physiological adaptation; CL: Synthesize

Question 40

40. The physician prescribes intestinal decompression with a Cantor tube for a client with an
    intestinal obstruction. In order to determine effectiveness of intestinal decompression, the nurse
    should evaluate the client to determine if:
41. Intestinal fluid and gas have been removed.
42. The client has had a bowel movement.
43. The client’s urinary output is adequate.
44. The client can sit up without pain.

Answer 40

40. 1. Intestinal decompression is accomplished with a Cantor, Harris, or Miller-Abbott tube.
       These 6- to 10-foot (180 to 300 cm) tubes are passed into the small intestine to the obstruction. They
       remove accumulated fluid and gas, relieving the pressure. The client will not have an adequate bowel
       movement until the obstruction is removed. The pressure from the distended intestine should not
       obstruct urinary output. While the client may be able to more easily sit up, and the pain caused by the
       intestinal pressure will be less, these are not the primary indicators for successful intestinal
       decompression.
       CN: Physiological adaptation; CL: Evaluate

Question 41

41. After insertion of a nasoenteric tube, the nurse should place the client in which position?
42. Supine.
43. Right side-lying.
44. Semi-Fowler’s.4. Upright in a bedside chair.

Answer 41

41. 2. The client is placed in a right side-lying position to facilitate movement of the mercury-
       weighted tube through the pyloric sphincter. After the tube is in the intestine, the client is turned from
       side to side or encouraged to ambulate to facilitate tube movement through the intestinal loops.
       Placing the client in the supine or semi-Fowler’s position, or having the client sitting out of bed in a
       chair will not facilitate tube progression.
       CN: Reduction of risk potential; CL: Apply

Question 42

42. The nurse preparing a client for insertion of a nasoduodenal tube should teach which of the
    following? Select all that apply.
43. The nose and throat will be numbed with a viscous anesthetic.
44. The tube will be placed at the bedside.
45. X-rays with the use of a contrast dye will be used to verify placement.
46. The client will be closely monitored for 30 minutes following the procedure.
47. The tube will be taped to the nose.

Answer 42

42. 1, 3, 4, 5. A nasoduodenal tube is used primarily for feeding. The tube is inserted in
    endoscopy or radiology. Prior to insertion, the client will use viscous xylocaine to anesthetize the
    throat. The tube placement is verified by contrast x-rays, and the client is observed for 30 minutes
    after the insertion to be sure the client does not have an allergic reaction, puncture to the lung, or
    bleeding. The tube is taped to the nose.
    CN: Reduction of risk potential; CL: Apply

Question 43

43. The client with an intestinal obstruction continues to have acute pain even though the
    nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
44. Reassure the client that the nasoenteric tube is functioning.
45. Assess the client for a rigid abdomen.
46. Administer an opioid as prescribed.
47. Reposition the client on the left side.

Answer 43

43. 2. The client’s pain may be indicative of peritonitis, and the nurse should assess for signs and
       symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client
       is important, but accurate assessment of the client is essential. The full assessment should occur
       before pain relief measures are employed. Repositioning the client to the left side will not resolve the
       pain.
       CN: Reduction of risk potential; CL: Synthesize

Question 44

44. Before abdominal surgery for an intestinal obstruction, the nurse monitors the client’s urine
    output and finds that the total output for the past 2 hours was 35 mL. The nurse then assesses the
    client’s total intake and output over the last 24 hours and notes 2,000 mL of IV fluid for intake, 500 mL
    of drainage from the nasogastric tube, and 700 mL of urine for a total output of 1,200 mL. These
    findings indicate which of the following?
45. Decreased renal function.
46. Inadequate pain relief.
47. Extension of the obstruction.
48. Inadequate fluid replacement.

Answer 44

44. 4. Considering that there is usually 1 L of insensible fluid loss, this client’s output exceeds his
       intake (intake, 2,000 mL; output, 2,200 mL), indicating deficient fluid volume. The kidneys are
       concentrating urine in response to low circulating volume, as evidenced by a urine output of less than
       30 mL/h. This indicates that increased fluid replacement is needed. Decreasing urine output can be a
       sign of decreased renal function, but the data provided suggest that the client is dehydrated. Pain does
       not affect urine output. There are no data to suggest that the obstruction has worsened.
       CN: Reduction of risk potential; CL: Analyze

Question 45

The Client with an Ileostomy
45. The nurse is teaching the client how to care for an ileostomy. The client asks the nurse how
long to wear the pouch before changing it. The nurse should tell the client which of the following?
1. “The pouch is changed only when it leaks.”
2. “You can wear the pouch for about 4 to 7 days.”
3. “You should change the pouch every evening before bedtime.”
4. “It depends on your activity level and your diet.”

Answer 45

The Client with an Ileostomy
45. 2. Unless the pouch leaks, the client can wear the ileostomy pouch for about 4 to 7 days. Ifleakage occurs, it is important to promptly change the pouch to avoid skin irritation. It is not
necessary to change the pouch daily or in the evening. Diet and activity typically do not affect the
schedule for changing the pouch.
CN: Basic care and comfort; CL: Synthesize

Question 46

46. A client is scheduled for an ileostomy. Which of the following interventions would be most
    helpful in preparing the client psychologically for the surgery?
47. Include family members in preoperative teaching sessions.
48. Encourage the client to ask questions about managing an ileostomy.
49. Provide a brief, thorough explanation of all preoperative and postoperative procedures.
50. Invite a member of the ostomy association to visit the client.

Answer 46

46. 3. Providing explanations of preoperative and postoperative procedures helps the client
       prepare and understand what to expect. It also provides an opportunity for the client to share
       concerns. Including family members in the teaching sessions is beneficial but does not focus on the
       client’s psychological preparation. Encouraging the client to ask questions about managing the
       ileostomy may be rushing the client psychologically into accepting the change in body image and
       function. The client may need time to first handle the stress of surgery and then observe the care of the
       ileostomy by others before it is appropriate to begin discussing self-management. The nurse should
       gently explore whether the client is ready to ask questions about management throughout the
       hospitalization. The client should have the opportunity to express concerns and to agree to an ostomy
       association visitor before an invitation is extended.
       CN: Psychosocial adaptation; CL: Synthesize

Question 47

47. The nurse should instruct a client who is scheduled for an ileostomy to do which of the
    following 2 weeks before surgery?
48. Stop taking drugs that will interfere with clotting (aspirin, ibuprofen).
49. Follow a low-residue diet.
50. Abstain from having sex.
51. Wear a mask when in public to prevent infection.

Answer 47

47. 1. The nurse should instruct the client to stop taking drugs that would interfere with clotting,
       such as aspirin or ibuprofen. The client should follow a high-fiber diet with increased fluids during
       the 2-week preoperative period. It is not necessary to abstain from sex. It is not necessary to wear a
       mask to prevent infection, but the client should report any infection during the preoperative period to
       the health care provider.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 48

48. Immediately after having surgery to create an ileostomy, which goal has the highest priority?
49. Providing relief from constipation.
50. Assisting the client with self-care activities.
51. Maintaining fluid and electrolyte balance.
52. Minimizing odor formation.

Answer 48

48. 3. A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte
       balance. The client will experience continuous liquid to semiliquid stools. The client should be
       engaged in self-care activities, and minimizing odor formation is important; however, these goals do
       not take priority over maintaining fluid and electrolyte balance.
       CN: Physiological adaptation; CL: Synthesize

Question 49

49. The client asks the nurse, “Is it really possible to lead a normal life with an ileostomy?”
    Which action by the nurse would be the most effective to address this question?
50. Have the client talk with a member of the clergy about these concerns.
51. Tell the client to worry about those concerns after surgery.
52. Arrange for a person with an ostomy to visit the client preoperatively.
53. Notify the surgeon of the client’s question.

Answer 49

49. 3. If the client agrees, having a visit by a person who has successfully adjusted to living with
       an ileostomy would be the most helpful measure. This would let the client actually see that typical
       activities of daily living can be pursued postoperatively. Someone who has felt some of the same
       concerns can answer the client’s questions. A visit from the clergy may be helpful to some clients but
       would not provide this client with the information sought. Disregarding the client’s concerns is not
       helpful. Although the physician should know about the client’s concerns, this in itself will not reassure
       the client about life after an ileostomy.
       CN: Psychosocial adaptation; CL: Synthesize

Question 50

50. Three weeks after the client has had an ileostomy, the nurse is following up with instruction
    about using a skin barrier around the stoma at all times. The client has been applying the skin barrier
    correctly when:
51. There is no odor from the stoma.
52. The client is adequately hydrated.
53. There is no skin irritation around the stoma.
54. The client only changes the ostomy pouch once a day

Answer 50

50. 3. Because of high concentrations of digestive enzymes, ileostomy effluent is irritating to skin
       and can cause excoriation and ulceration. Some form of protection must be used to keep the effluent
       from contacting the skin. A skin barrier does not decrease odor formation; odor is controlled by diet.
       The barrier does not affect the client’s hydration status, and the nurse can encourage the client to have
       an adequate daily intake of fluids. Pouches are usually worn for 4 to 7 days before being changed.
       CN: Basic care and comfort; CL: Evaluate

Question 51

mediately?

1. Passage of liquid stool from the stoma.2. Occasional presence of undigested food in the effluent.
2. Absence of drainage from the ileostomy for 6 or more hours.
3. Temperature of 99.8°F (37.7°C).

Answer 51

51. 3. Any sudden decrease in drainage or onset of severe abdominal pain should be reported tothe physician immediately because it could mean that an obstruction has developed. The ileostomy
       drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times.
       A temperature of 99.8°F (37.7°C) is not necessarily abnormal or a cause for concern.
       CN: Reduction of risk potential; CL: Synthesize

Question 52

52. The nurse finds the client who has had an ileostomy crying. The client explains to the nurse,
    “I’m upset because I know I won’t be able to have children now that I have an ileostomy.” Which of
    the following would be the best response for the nurse?
53. “Many women with ileostomies decide to adopt. Why don’t you consider that option?”
54. “Having an ileostomy does not necessarily mean that you can’t bear children. Let’s talk about
    your concerns.”
55. “I can understand your reasons for being upset. Having children must be important to you.”
56. “I’m sure you will adjust to this situation with time. Try not to be too upset.”

Answer 52

52. 2. The fact that the client has an ileostomy does not necessarily mean that she cannot get
       pregnant and bear children. It may be recommended, however, that the number of pregnancies be
       limited. Women of childbearing age should be encouraged to discuss their concerns with their
       physician. Discussing their concerns about sexual functioning and pregnancy will help decrease fears
       and anxiety. Empathizing or telling the woman that she can adopt does not address her concerns. Her
       current fears may be based on erroneous understanding. Telling the client that she will adjust to the
       situation ignores her concerns.
       CN: Psychosocial adaptation; CL: Synthesize

Question 53

3. Which of the following statements about ileostomy care indicates that the client understands
   the discharge instruction?
4. “I should be able to resume weight lifting in 2 weeks.”
5. “I can return to work in 2 weeks.”
6. “I need to drink at least 3,000 mL a day of fluid.”
7. “I will need to avoid getting my stoma wet while bathing.”

Answer 53

53. 3. To maintain an adequate fluid balance, the client needs to drink at least 3,000 mL/day.
       Heavy lifting should be avoided; the physician will indicate when the client can participate in sports
       again. The client will not resume working as soon as 2 weeks after surgery. Water does not harm the
       stoma, so the client does not have to worry about getting it wet.
       CN: Physiological adaptation; CL: Evaluate

Question 54

54. A client with a well-managed ileostomy has sudden onset of abdominal cramps, vomiting,
    and watery discharge from the ileostomy. The nurse should:
55. Tell the client to take an antiemetic.
56. Encourage the client to increase fluid intake to 3 L/day to replace fluid lost through vomiting.
57. Instruct the client to take 30 mL of milk of magnesia to stimulate a bowel movement.
58. Notify the physician.

Answer 54

54. 4. Sudden onset of abdominal cramps, vomiting, and watery discharge with no stool from an
       ileostomy are likely indications of an obstruction. It is imperative that the physician examine the
       client immediately. Although the client is vomiting, the client should not take an antiemetic until the
       physician has examined the client. If an obstruction is present, ingesting fluids or taking milk of
       magnesia will increase the severity of symptoms. Oral intake is avoided when a bowel obstruction is
       suspected.
       CN: Reduction of risk potential; CL: Synthesize

Question 55

The Client Receiving Total Parenteral Nutrition
55. The nurse is changing the subclavian dressing of a client who is receiving total parenteral
nutrition. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage
from around the sutures that are anchoring the catheter. Which action should the nurse take first?
1. Clean the insertion site and redress the area.
2. Document assessment findings in the client’s chart.
3. Obtain a culture specimen of the drainage.
4. Notify the physician.

Answer 55

The Client Receiving Total Parenteral Nutrition
55. 3. The nurse should first obtain a culture specimen. The presence of drainage is a potential
indication of an infection and the catheter may need to be removed. A culture specimen should be
obtained and sent for analysis so that treatment can be promptly initiated. Since removing the catheter
will be required in the presence of an infection, the nurse would not clean and redress the area. After
the culture report is obtained, the nurse should notify the physician and document all assessments and
client care activities in the client’s record.
CN: Safety and infection control; CL: Synthesize

Question 56

56. Total parenteral nutrition (TPN) is prescribed for a client with who has recently had a small
    and large bowel resection, and who is currently not taking anything by mouth. The nurse should:
57. Administer TPN through a nasogastric or gastrostomy tube.
58. Handle TPN using strict aseptic technique.
59. Auscultate for the presence of bowel sounds prior to administering TPN.
60. Designate a peripheral intravenous (IV) site for TPN administration.

Answer 56

56. 2 Total parenteral nutrition (TPN) is a hypertonic, high-calorie, high-protein intravenous (IV)
    fluid that should be provided for clients who do not have functional gastrointestinal track motility, in
    order to better meet metabolic needs of the client, and to support optimal nutrition and healing. TPN
    is prescribed once daily, based on the client’s current electrolyte and fluid balance, and must be
    handled with strict aseptic technique (due to the high glucose content, it is a perfect medium for
    bacterial growth). Also, because of the high tonicity, TPN must be administered through a central
    venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to
    determine whether TPN can safely be administered.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 57

57. Using a sliding-scale schedule, the nurse is preparing to administer an evening dose of
    regular insulin to a client who is receiving total parenteral nutrition (TPN). Which action is most
    appropriate for the nurse to take to determine the amount of insulin to give?
58. Base the dosage on the glucometer reading of the client’s glucose level obtained immediately
    before administering the insulin.
59. Base the dosage on the fasting blood glucose level obtained earlier in the day.
60. Calculate the amount of TPN fluid the client has received since the last dose of insulin and
    adjust the dosage accordingly.
61. Assess the client’s dietary intake for the evening meal and snack and adjust the dosage
    accordingly.

Answer 57

57. 1. When using a sliding-scale insulin schedule, the nurse obtains a glucometer reading of the
       client’s blood glucose level immediately before giving the insulin and bases the dosage on those
       findings. The fasting blood glucose level obtained earlier in the day is not relevant to an evening
       sliding-scale insulin dosage. The nurse cannot calculate insulin dosage by assessing the amount of
       TPN intake or dietary intake.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 58

58. A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The
    basic component of the client’s TPN solution is most likely to be:
59. An isotonic dextrose solution.
60. A hypertonic dextrose solution.
61. A hypotonic dextrose solution.
62. A colloidal dextrose solution.

Answer 58

58. 2. The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of
       dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body’s
       calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic
       dextrose solution (eg, 5% dextrose in water) or a hypotonic dextrose solution will not provide enough
       calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not
       used in TPN.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 59

59. A nurse is assisting with the removal a of central venous access device (CVAD). The nurse
should instruct the client to:
1. Turn to the left side.
2. Exhale slowly and evenly.
3. Turn to the right side.
4. Take a deep breath and hold it.

Answer 59

59. 4. The client should be asked to perform the Valsalva maneuver (take a deep breath and hold
       it) during insertion and removal of a CVAD. This increases central venous pressure during the
       procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insertion
       and removal. If not possible, supine position is sufficient for CVAD removal. The client should hold
       the breath, not exhale.
       CN: Physiological integrity; CL: Apply

Question 60

60. TPN is prescribed for a client with Crohn’s disease. Which of the following indicate the TPN
    solution is having an intended outcome?
61. There is increased cell nutrition.
62. The client does not have metabolic acidosis.
63. The client is hydrated.4. The client is in a negative nitrogen balance.

Answer 60

60. 1. The goal of TPN is to meet the client’s nutritional needs. TPN is not used to treat metabolic
       acidosis; ketoacidosis can actually develop as a result of administering TPN. TPN is a hypertonic
       solution containing carbohydrates, amino acids, electrolytes, trace elements, and vitamins. It is not
       used to meet the hydration needs of clients. TPN is administered to provide a positive nitrogen
       balance.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 61

61. A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a
    client’s ability to metabolize the TPN solution adequately by monitoring the client for which of the
    following signs?
62. Tachycardia.
63. Hypertension.
64. Elevated blood urea nitrogen concentration.
65. Hyperglycemia.

Answer 61

61. 4. During TPN administration, the client should be monitored regularly for hyperglycemia.
       The client may require small amounts of insulin to improve glucose metabolism. The client should
       also be observed for signs and symptoms of hypoglycemia, which may occur if the body
       overproduces insulin in response to a high glucose intake or if too much insulin is administered to
       help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client’s ability
       to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status
       and fluid balance.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 62

62. Which of the following interventions should the nurse include in the client’s plan of care to
    prevent complications associated with TPN administered through a central line?
63. Use a clean technique for all dressing changes.
64. Tape all connections of the system.
65. Encourage bed rest.
66. Cover the insertion site with a moisture-proof dressing

Answer 62

62. 2. Complications associated with administration of TPN through a central line include
       infection and air embolism. To prevent these complications, strict aseptic technique is used for all
       dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of
       the system are taped. Ambulation and activities of daily living are encouraged and not limited during
       the administration of TPN.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 63

63. The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a
    client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no
    abnormal breath sounds. The nurse should do the following in order of what priority from first to
    last?
64. Change dressing per institutional policy.
65. Culture drainage at insertion site.
66. Notify physician.
67. Position rolled towel under client’s back, parallel to the spine.

Answer 63

63.3. Notify physician.
4. Position rolled towel under client’s back, parallel to the spine.
2. Culture drainage at insertion site.
1. Change dressing per institutional policy.
A potential complication of receiving TPN is leakage or catheter puncture; the nurse should first
notify the physician and prepare for changing of the catheter. Next, if pneumothorax is suspected,
position a rolled towel under the client’s back. If there is drainage at the insertion site, the nurse
should then obtain a culture from the drainage and lastly, change the dressing using sterile technique.
CN: Reduction of risk potential; CL: Synthesize

Question 64

64. The nurse administers fat emulsion solution during TPN as prescribed based on the
    understanding that this type of solution:
65. Provides essential fatty acids.
66. Provides extra carbohydrates.
67. Promotes effective metabolism of glucose.
68. Maintains a normal body weight.

Answer 64

64. 1. The administration of fat emulsion solution provides additional calories and essential fatty
       acids to meet the body’s energy needs. Fatty acids are lipids, not carbohydrates. Fatty acids do not aid
       in the metabolism of glucose. Although they are necessary for meeting the complete nutritional needs
       of the client, fatty acids do not necessarily help a client maintain normal body weight.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 65

65. Which of the following should the nurse interpret as an indication of a complication after the
    first few days of TPN therapy?
66. Glycosuria.
67. A 1- to 2-lb (0.45- to 0.9-kg) weight gain.
68. Decreased appetite.
69. Elevated temperature.

Answer 65

65. 4. An elevated temperature can be an indication of an infection at the insertion site or in the
       catheter. Vital signs should be taken every 2 to 4 hours after initiation of TPN therapy to detect early
       signs of complications. Glycosuria is to be expected during the first few days of therapy until the
       pancreas adjusts by secreting more insulin. A gradual weight gain is to be expected as the client’s
       nutritional status improves. Some clients experience a decreased appetite during TPN therapy.
       CN: Reduction of risk potential; CL: Analyze

Question 66

66. Which of the following adverse effects occur when there is too rapid an infusion of TPN
solution?
1. Negative nitrogen balance.
2. Circulatory overload.
3. Hypoglycemia.
4. Hypokalemia.

Answer 66

66. 2. Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be
       assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in
       nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is
       administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes.
       Therefore, the client is at risk for hyperglycemia and hyperkalemia.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 67

The Client with Diverticular Disease
67. Following the acute stage of diverticulosis, which foods should the nurse encourage a client
to incorporate into the diet? Select all that apply.
1. Bran cereal.
2. Broccoli.
3. Tomato juice.
4. Navy beans.
5. Cheese.

Answer 67

The Client with Diverticular Disease
67. 1, 2, 4. Clients with diverticulosis are encouraged to follow a high-fiber diet. Bran, broccoli,
and navy beans are foods high in fiber. Tomato juice and cheese are low-residue foods.
CN: Reduction of risk potential; CL: Apply

Question 68

68. Which of the following laboratory findings are expected when a client has diverticulitis?
69. Elevated red blood cell count.
70. Decreased platelet count.
71. Elevated white blood cell count.
72. Elevated serum blood urea nitrogen concentration.

Answer 68

68. 3. Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated
       white blood cell count. The remaining laboratory findings are not associated with diverticulitis.
       Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit.
       Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, asan adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood
       urea nitrogen concentration is usually associated with renal conditions.
       CN: Reduction of risk potential; CL: Analyze

Question 69

69. A barium enema is not prescribed as a diagnostic test for a client with diverticulitis because
    a barium enema:
70. Can perforate an intestinal abscess.
71. Would greatly increase the client’s pain.
72. Is of minimal diagnostic value in diverticulitis.
73. Is too lengthy a procedure for the client to tolerate.

Answer 69

69. 1. Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis
       because they can lead to perforation of the colon and peritonitis. A barium enema may be prescribed
       after the client has been treated with antibiotic therapy and the inflammation has subsided. A barium
       enema is diagnostic in diverticulitis. A barium enema could increase the client’s pain; however, that is
       not a reason for excluding this test. The client may be able to tolerate the procedure but the concern is
       the potential for perforation of the intestine.
       CN: Reduction of risk potential; CL: Apply

Question 70

70. The nurse should teach the client with diverticulitis to integrate which of the following into a
    daily routine at home?
71. Using enemas to relieve constipation.
72. Decreasing fluid intake to increase the formed consistency of the stool.
73. Eating a high-fiber diet when symptomatic with diverticulitis.
74. Refraining from straining and lifting activities.

Answer 70

70. 4. Clients with diverticular disease should refrain from any activities, such as lifting,
       straining, or coughing, that increase intra-abdominal pressure and may precipitate an attack. Enemas
       are contraindicated because they increase intestinal pressure. Fluid intake should be increased, rather
       than decreased, to promote soft, formed stools. A low-fiber diet is used when inflammation is
       present.
       CN: Reduction of risk potential; CL: Synthesize

Question 71

71. After instructing a client with diverticulosis about appropriate self-care activities, which of
    the following client comments indicate effective teaching? Select all that apply.
72. “With careful attention to my diet, my diverticulosis can be cured.”
73. “Using a cathartic laxative weekly is okay to control bowel movements.”
74. “I should follow a diet that’s high in fiber.”
75. “It is important for me to drink at least 2,000 mL of fluid every day.”
76. “I should exercise regularly.”

Answer 71

71. 3, 4, 5. Clients who have diverticulosis should be instructed to maintain a diet high in fiber
    and, unless contraindicated, should increase their fluid intake to a minimum of 2,000 mL/day.
    Participating in a regular exercise program is also strongly encouraged. Diverticulosis can be
    controlled with treatment but cannot be cured. Clients should be instructed to avoid the regular use of
    cathartic laxatives. Bulk laxatives and stool softeners may be helpful to maintain regularity and
    decrease straining.
    CN: Reduction of risk potential; CL: Evaluate

Question 72

72. A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil).
    The drug has been effective when the client:
73. Passes stool without cramping.
74. Does not have diarrhea.
75. Is no longer anxious.
76. Does not expel gas.

Answer 72

72. 1. Diverticular disease is treated with a high-fiber diet and bulk laxatives such as psyllium
       hydrophilic mucilloid (Metamucil). Fiber decreases the intraluminal pressure and makes it easier for
       stool to pass through the colon. Bulk laxatives do not manage diarrhea, anxiety or relieve gas
       formation.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 73

73. A client with diverticulitis has developed peritonitis following diverticular rupture. When
    assessing the client, the nurse should do which of the following? Select all that apply.
74. Percuss the abdomen to note resonance and tympany.
75. Percuss the liver to note lack of dullness.
76. Monitor the vital signs for fever, tachypnea, and bradycardia.
77. Assess presence of polyphagia and polydipsia.
78. Auscultate bowel sounds to note frequency.

Answer 73

73. 1, 2, 5. Assessment during peritonitis will reveal fever, tachypnea, and tachycardia. The
    abdomen becomes rigid with rebound tenderness and there will be absent bowel sounds. Percussion
    will show resonance and tympany indicating paralytic ileus; loss of liver dullness may indicate free
    air in the abdomen. There is anorexia, nausea, and vomiting as peristalsis decreases.
    CN: Physiological adaptation; CL: Analyze

Question 74

The Client with Appendicitis
74. A nurse is providing wound care to a client 1 day following an appendectomy. A drain was
inserted into the incisional site during surgery. Which action should the nurse perform when providing
wound care?
1. Remove the dressing and leave the incision open to air.
2. Remove the drain if wound drainage is minimal.
3. Gently irrigate the drain to remove exudate.
4. Clean the area around the drain moving away from the drain.

Answer 74

The Client with Appendicitis
74. 4. The nurse should gently clean the area around the drain by moving in a circular motion
away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain
site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the
amount and character of wound drainage, but the surgeon will determine when the drain should be
removed. Surgical wound drains are not irrigated.
CN: Safety and infection control; CL: Synthesize

Question 75

75. The nurse is admitting a client with acute appendicitis to the emergency department. The
    client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon
    as possible. The nurse should:
76. Contact the surgeon to request a prescription for a narcotic for the pain.
77. Maintain the client in a recumbent position.
78. Place the client on nothing-by-mouth (NPO) status.
79. Apply heat to the abdomen in the area of the pain.

Answer 75

75. 3. The nurse should place the client on NPO status in anticipation of surgery. The nurse can
       initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe
       narcotic medication prior to surgery. The nurse can place the client in a position that is most
       comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.
       CN: Reduction of risk potential; CL: Synthesize

Question 76

76. A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on
    these findings, the nurse should further assess the client for which of the following complications?
77. Deficient fluid volume.
78. Intestinal obstruction.
79. Bowel ischemia.
80. Peritonitis.

Answer 76

76. 4. Complications of acute appendicitis are perforation, peritonitis, and abscess development.
       Signs of the development of peritonitis include abdominal pain and distention, tachycardia,
       tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock,
       hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction
       would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel
       ischemia has signs and symptoms similar to those found with intestinal obstruction.
       CN: Physiological adaptation; CL: Analyze

Question 77

77. Postoperative nursing care for a client after an appendectomy should include which of the
    following?
78. Administering sitz baths four times a day.
79. Noting the first bowel movement after surgery.
80. Limiting the client’s activity to bathroom privileges.
81. Measuring abdominal girth every 2 hours.

Answer 77

77. 2. Noting the client’s first bowel movement after surgery is important because this indicates
       that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy.
       Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen
       should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the
       girth every 2 hours.
       CN: Physiological adaptation; CL: Synthesize

Question 78

78. A client who had an appendectomy for a perforated appendix returns from surgery with a
    drain inserted in the incisional site. The purpose of the drain is to:
79. Provide access for wound irrigation.
80. Promote drainage of wound exudates.
81. Minimize development of scar tissue.
82. Decrease postoperative discomfort.

Answer 78

78. 2. Drains are inserted postoperatively in appendectomies when an abscess was present or the
       appendix was perforated. The purpose is to promote drainage of exudate from the wound and
       facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar
       tissue development or decrease postoperative discomfort.
       CN: Reduction of risk potential; CL: Apply

Question 79

The Client with an Inguinal Hernia
79. A client who has a history of an inguinal hernia is admitted to the hospital with sudden,
severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further
for which of the following complications?
1. Peritonitis.
2. Incarcerated hernia.
3. Strangulated hernia.
4. Intestinal perforation.

Answer 79

The Client with an Inguinal Hernia
79. 3. The symptoms are indicative of a strangulated hernia. In a strangulated hernia, the hernia
cannot be reduced back into the abdominal cavity. The intestinal lumen and the blood supply to the
intestine are obstructed, causing an acute intestinal obstruction. Without immediate intervention,
necrosis and gangrene may develop. Surgery is required to release the strangulation. Although many
of these signs and symptoms are present with peritonitis or perforated bowel, abdominal rigidity, a
cardinal sign of peritonitis and perforated bowel, is not mentioned. Therefore, the nurse would not
immediately suspect these conditions. An incarcerated hernia refers to a hernia that is irreducible but
has not necessarily resulted in an obstruction.
CN: Physiological adaptation; CL: Analyze

Question 80

80. A male client has just had an inguinal herniorrhaphy. Which of the following instructions
    would be most appropriate to include in the discharge plan?
81. Turning, coughing, and deep breathing every 2 hours.
82. Applying an ice bag to the scrotum.
83. Applying a truss before the client ambulates.
84. Maintaining a high Fowler’s position while resting.

Answer 80

80. 2. After inguinal herniorrhaphy, an ice bag to the scrotum will help decrease pain and edema.
       The client is encouraged to turn and deep breathe, but coughing is not encouraged, to decrease
       straining on the surgical area. A truss is not needed for support after surgery. While resting, the client
       may be most comfortable in a semi-Fowler’s position, but there is no need to maintain a high Fowler’s
       position.
       CN: Physiological adaptation; CL: Synthesize

Question 81

81. After an inguinal herniorrhaphy, the nurse should assess the male client carefully for which of
the following likely complications?
1. Hypostatic pneumonia.
2. Deep vein thrombosis.
3. Paralytic ileus.
4. Urine retention.

Answer 81

81. 4. The most common complication after an inguinal hernia repair is the inability to void,especially in men. The nurse should evaluate the client carefully for urine retention. Hypostatic
       pneumonia, deep vein thrombosis, and paralytic ileus are potential postoperative problems with any
       surgical client but are not as likely to occur after an inguinal hernia repair as is urine retention.
       CN: Reduction of risk potential; CL: Analyze

Question 82

Managing Care Quality and Safety
82. The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should
do which of the following to prevent the spread of infection? Select all that apply.
1. Wear a particulate respirator.
2. Wear sterile gloves when providing care.
3. Cleanse hands with alcohol-based hand sanitizer.
4. Wash hands with soap and water.
5. Wear a protective gown when in the client’s room.

Answer 82

Managing Care Quality and Safety
82. 4, 5. Clostridium difficile is an organism that has developed very resistant and highly morbid
strains. Universal precautions, most importantly handwashing, wearing personal protective gear, and
modest use of antibiotics, are critical actions for stopping the spread. C. difficile is not spread via the
respiratory tract; therefore, a mask is not needed. Alcohol-based hand sanitizers do not kill the spores
of C. difficile; soap and water must be used. Sterile gloves are not needed to provide care; clean
gloves may be worn.
CN: Safety and infection control; CL: Synthesize

Question 83

83. The nurse discovers that a client’s TPN solution was running at an incorrect rate and is now 2
    hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem?
84. Readjust the solution to infuse the desired amount.
85. Continue the infusion at the current rate, but run the next bottle at an increased rate.
86. Double the infusion rate for 2 hours.
87. Notify the physician.

Answer 83

83. 4. When TPN fluids are infused too rapidly or too slowly, the physician should be notified.
       TPN solutions must be carefully and accurately infused. Rate adjustments should not be made without
       a written prescription from the physician. Significant alterations in rate (10% increase or decrease)
       can result in fluctuations of blood glucose levels. Speeding up the solution can result in too much
       glucose entering the system.
       CN: Management of care; CL: Synthesize

Question 84

84. The nurse is to administer ampicillin 500 mg orally to a client with a ruptured appendix. The
    nurse checks the capsule in the client’s medication box, which is located inside of the client’s room.
    The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the
    capsule. The nurse should next:
85. Administer the medication to maintain blood levels of the drug.
86. Ask another registered nurse to verify that the capsule is ampicillin.
87. Contact the pharmacy to bring a properly labeled medication.
88. Notify the unit manager to report the problem.

Answer 84

84. 3. The nurse should contact the pharmacy directly and request that a properly labeled
       medication be provided. The nurse should not administer any drug that is not properly labeled, even if
       the nurse or another nurse recognizes the medication. It is not necessary to notify the unit manager at
       this point because the client needs to receive the antibiotic as soon as possible.
       CN: Safety and infection control; CL: Apply

Question 85

85. On the second day following an abdominal perineal resection, the nurse notes that the wound
    edges are not approximated and one-half the incision has torn apart. The nurse should take what
    action first?
86. Flush the wound with sterile water.
87. Apply an abdominal binder.
88. Cover the wound with a sterile dressing moistened with normal saline.
89. Apply strips of tape.

Answer 85

85. 3. When dehiscence occurs, the nurse should immediately cover the wound with a sterile
       dressing moistened with normal saline. If the dehiscence is extensive, the incision must be resutured
       in surgery. Later, after the sutures are removed, additional support may be provided to the incision by
       applying strips of tape as directed by institutional policy or by the surgeon. An abdominal binder may
       also be utilized for additional support.
       CN: Reduction of risk potential; CL: Synthesize

Question 86

86. A client has received numerous different antibiotics and now is experiencing diarrhea. The
    physician has prescribed a transmission-based precaution. Which of the following types of
    precautions would be most appropriate for all personnel to use?
87. Airborne precautions.
88. Contact precautions.
89. Droplet precautions.
90. Needlestick precautions.

Answer 86

86. 2. Airborne precautions are required for clients with presumed or proven pulmonary
       tuberculosis (TB), chickenpox, or other airborne pathogens. Contact precautions are used for
       organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or
       Clostridium difficile. Droplet precautions are used for organisms such as influenza or
       meningococcus that can be transmitted by close respiratory or mucous membrane contact with
       respiratory secretions. The most important aspect of reducing the risk of bloodborne infection is
       avoidance of percutaneous injury. Extreme care is essential when needles, scalpels, and other sharp
       objects are handled.
       CN: Safety and infection control; CL: Apply

Question 87

87. The physician has prescribed ciprofloxacin (Cipro) for a client who takes warfarin
    (Coumadin). The nurse should instruct the client to do which of the following while taking this drug?
    Select all that apply.
88. Split the tablets and stir them in food.
89. Avoid exposure to sunlight.3. Eliminate caffeine from the diet.
90. Report unusual bleeding.
91. Increase fluid intake to 3,000 mL/day.

Answer 87

87. 2, 4. A Black Box Warning for ciprofloxacin (Cipro) is that ciprofloxacin (Cipro) may
    increase the anticoagulant effects of warfarin (Coumadin). The nurse should instruct the client toreport increased bleeding and to monitor the prothrombin time (PT) and the international normalized
    ratio (INR) closely. Although there is a drug-food interaction and taking ciprofloxacin (Cipro) may
    increase the stimulatory effect of caffeine, the client does not need to eliminate caffeine, but should
    report signs of stimulant effect. Ciprofloxacin (Cipro) may cause photosensitivity reactions; the nurse
    must advise the client to avoid excessive sunlight or artificial ultraviolet light during therapy. Clients
    must be advised not to crush, split, or chew the extended-release tablets. It is not necessary to
    increase the amount of fluids.
    CN: Pharmacological and parenteral therapies; CL: Synthesize