The Gastrointestinal System

Question 1

What are the four main components of the digestive system?

Answer 1

1. GI tract
2. Pancreas, gall bladder, liver
3. Enzymes, hormones, nerves, blood
4. Mesentery – tissue that supports digestive organs

Question 2

Outline the process of digestion

Answer 2

1. saliva produced in response to food
2. churning and mixing with saliva turns food into bolus.
3. Saliva breaks down starch/sugar.
4. bolus passes through esophagus to the stomach.
5. Stomach nerves sense food and trigger peristalsis.
6. Stomach mixes and churns bolus with acid and enzymes that break down proteins. This stimulates the pancreas, liver, and gallbladder to produce digestive juices. Bile secreted by the gallbladder.
7. bolus moves into small intestine, where bile is secreted by the gall bladder.
8. The duodenum dissolves fats to be digested by pancreatic juices and bile. Carbs get converted into glucose, fats to triglycerides and fatty acids, and proteins into amino acids.
9. Enzymes are absorbed into the ilium
10. water, fibre, and waste move into the colon and body signals defecation.

Question 3

Total Parenteral Nutrition

Answer 3

nutrition delivered intravenously
- contains dextrose, amino acids, electrolytes
Indications: enteral nutrition is contraindicated or the patient is unable to tolerate; increased aspiration risk; GI obstruction
Complications: infection (change bag and tubing q24h; refrigerate until hanging bag), fluid overload (daily weights; check lytes), hyper/hypoglycemia (don’t stop abruptly; give 10% dextrose if bag runs out; titrate when turning up or down; check BG q4-6h); embolism.

Question 4

Laxatives

Answer 4

Action: Produce immediate BM
Examples: Lactulose, bisacodyl, milk of magnesia, PEG, Senna

Question 5

Stool Softeners

Answer 5

Action: pulls water into the GI tract
Example: Docusate

Question 6

Antidiarrheals

Answer 6

Loperamide
Diphenoxylate
Bismuth

Question 7

Antiemetics: Ondansteron

Answer 7

Indication: nausea, vomiting
Action: blocks effects of serotonin on the vagal nerve and CNS
Considerations: administer slowly; fast IV push can cause prolongation of QT interval and ventricular tachycardia.

Question 8

Antiulcer Agents

Answer 8

H2 Receptor Blockers
PPIs
Antacids
GI protectants

Question 9

Famotidine

Answer 9

Pharm Class: H2 Receptor Blocker
Action: blocks release of histamine and gastric acid secretion
indication: GERD; hypersecretory conditions; GI distress
Considerations: monitor kidney function and CBC; use short term.

Question 10

Omeprazole

Answer 10

Pharm Class: PPI
Indications: GERD and ulcers
Action: Prevents H+ transport into gastric lumen; decreases gastric acid secretion production.
Considerations: administer 30-60 mins before meals; report black, tarry stools ( ulceration may cause bleeding).

Question 11

Sucralfate

Answer 11

Indication: Ulcers; GERD
Action: promotes healing by providing a barrier and binding to proteins excreted by damaged ulceration tissue.
Considerations: avoid antibiotics for 2 hours; may decrease bioavailability of warfarin, digoxin, phenytoin, and levothyroxine; take on empty stomach; avoid antacids within 30 mins; caution with renal failure; monitor BG in diabetics.

Question 12

Nasogastric Tube

Answer 12

tube inserted into the nare that terminates in the stomach
Indication: enteral nutrition, decompression, med amin, removal of stomach contents following overdose.

Question 13

How is placement for NG tube verified?

Answer 13

chest x-ray
May also test residuals for pH (If residuals more than 500mL, hold the feed)

Question 14

Blakemore tube

Answer 14

tube inserted into the esophagus to the stomach that balloons to stop bleeding along the esophagus
Considerations: keep scissors at bedside.

Question 15

Function of the small intestine

Answer 15

absorbs nutrients
churns and mixes digested foods with mucous and enzymes, creating chyme; receives digestive juices from pancreas and liver.

Question 16

Function of the large intestine

Answer 16

absorbs H20 and electrolytes; produces and absorbs vitamins; forms and propels feces towards the rectum

Question 17

Ulcerative Colitis

Answer 17

inflammation of the large intestines, producing ulcerated surfaces that appear to be patchy

Question 18

Crohn’s Disease

Answer 18

Inflammation and erosion of the ileum and anywhere else throughout the small intestine and large intestine.

Question 19

Treatment for Crohn’s

Answer 19

LOW Fibre diet*
avoid hot/cold foods
steroids
no smoking
antidiarrheals
antibiotics
severe cases may involve removing portion of intestine with ostomy for relief.

Question 20

Appendicitis

Answer 20

inflammation of the appendix

Question 21

Signs and Symptoms of Appendicitis

Answer 21

pain begins with full, steady periumbilical pain
over 4-6 hrs, pain progresses and localizes to RLQ pain
nausea, vomiting
increased temperature
anorexia
increased WBC
Sudden relief may indicate burst appendix, which can lead to peritonitis
McBurney’s Sign (rebound tenderness of RLQ)

Question 22

Pre-op positioning for appendectomy

Answer 22

no heat (induces rupture)
right-sided fowlers

Question 23

Post-op Appendectomy Care

Answer 23

IV ABx
Pain management
NPO until return of bowel sounds
wound care

Question 24

Endocrine Function of the pancreas

Answer 24

regulates blood glucose by releasing insulin and glucagon

Question 25

Exocrine function of the pancreas

Answer 25

secretes tyrupsin, amylase, lipase, into the duodenum to digest carbs, fats, and proteins.

Question 26

Pathophysiology of pancreatitis

Answer 26

digestive enzymes activate inside the pancreas, causing auto digestion of the pancreas; prevents secretion of digestive enzymes into the common bile duct, producing abdominal pain.

Question 27

Signs and Symptoms of Pancreatitis

Answer 27

pain that increases with food intake
abdominal distention
ascites
rigid abdomen
Turner’s Sign (discolouration of the flank)
Nausea Vomiting
Jaundice
Hypotension
Bruising over flank/side

Question 28

Treatment for Acute Pancreatitis

Answer 28

Labs: WBC, lipase
NPO
IV Fluids
Pain control (dilaudid)
Antispasmodic drugs to reduce gut motility
calcium replacement
TPN (promotes pancreatic rest)
electrolyte replacement
antibiotics for fever
Corticosteroids

Question 29

Liver Function

Answer 29

produces bile, albumin, cholesterol; converts glucose into glycogen fro storage; converts ammonia to urea; metabolizes bilirubin in the breakdown of RBC; metabolizes drugs and toxins; produces clotting factors and regulates blood clotting.

Question 30

Complications of cirrhosis

Answer 30

liver failure

Question 31

Transmission of hepatitis A

Answer 31

fecal/oral

Question 32

Transmission of hepatitis B

Answer 32

Body fluids

Question 33

Transmission of hepatitis C

Answer 33

Body fluids and contact with dirty medical equipment

Question 34

Transmission of hepatitis D

Answer 34

contact with infected body fluids (must already have Hep B)

Question 35

Transmission of Hepatitis E

Answer 35

Fecal/oral

Question 36

Treatment of Hepatitis A

Answer 36

supportive care

Question 37

Treatment of Hepatitis B

Answer 37

Acute = supportive
Long-term = antiviral treatment

Question 38

Treatment of Hepatitis C

Answer 38

Direct-acting antivirals

Question 39

Treatment of Hepatitis D

Answer 39

no treatment

Question 40

Treatment for Hepatitis E

Answer 40

supportive

Question 41

Health promotion for Hep A

Answer 41

vaccination and hygeine

Question 42

health promotion for Hep B

Answer 42

vaccination, blood screening, hygeine

Question 43

health promotion for Hep C

Answer 43

Blood screen, sanitary healthcare environment.

Question 44

health promotion for Hep D

Answer 44

blood screen; use of sterile needles

Question 45

health promotion for Hep E

Answer 45

improved hygeine and sanitation.

Question 46

Cirrhosis

Answer 46

disease of the liver caused by chronic alcoholism or acute hepatitis; marked by degeneration of liver cells, inflammation, and fibrous thickening of tissue; cells are replaced with scar tissue; impairs blood flow, leading to portal hypertension

Question 47

Assessment of Patient with Cirrhosis

Answer 47

palpable, firm liver
abdominal pain
dyspepsia
decreased serum albumin
ascites
splenomegaly
increased AST/ALT
dysfunction of clotting factors (increased risk for bleeding)
risk for anemia
fatigue
nausea/vomiting
spider veins

Question 48

Treatment for Cirrhosis

Answer 48

Antacids
vitamins
diuretics
paracentesis
low protein, low sodium diet
daily weights
strict ins/outs
bleed precautions
skin care
be careful with drug doses

Question 49

Total Parenteral Nutrition Indications

Answer 49

Enteral nutrition contraindicated
client not tolerant of enteral nutrition
high risk for aspiration
GI obstruction

Question 50

Complications of TPN

Answer 50

infection
fluid overload
hypo/hyperglycemia
embolism

Question 51

BG collection

Answer 51

✓ When collecting capillary blood glucose (CBG), the glucometer should be calibrated and in good working order

✓ CBG specimens should be collected from the lateral side of a finger that has been cleaned with isopropyl alcohol

✓ If a client is critically ill with a low hematocrit level, receiving vasopressors, or hypotensive, the CBG result may be inaccurate

Question 52

Prednisone decreases the absorption of which electrolyte?

Answer 52

calcium; reduces serum calcium levels in patients with hyperparathyroidism

Question 53

Causes of hypocalcemia

Answer 53

Celiac; Crohn’s; hypoparathyroid; hyperphosphatemia; alcoholism; malnutrition; malabsorption; pancreatitis

Question 54

How does hypoparathyroidism cause hyperphosphatemia and hypocalcemia?

Answer 54

Hypoparathyroidism is a cause of hyperphosphatemia. The client who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels (hypocalcemia). Since calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus. Thus, hypoparathyroidism causes hyperphosphatemia.

Question 55

Determine the syndrome indicated by the following labs:
HA1C - 5.9%
BP – 155/82
Cholesterol – 218
BMI – 27

Answer 55

This client is showing evidence of metabolic syndrome and needs prompt intervention to mitigate the risk of diabetes mellitus. Nutritional intervention is necessary because this client needs to modify their diet and reduce their intake of sodium, fats, and simple carbohydrates. Thus, it would be appropriate for the nurse to initiate a referral to a registered dietician.

Question 56

Metabolic Syndrome

Answer 56

Metabolic syndrome is when the client has three out of the five abnormalities –

✓ Hypercholesterolemia (> 200 mg/dl)

✓ High triglycerides (> 150 mg/dl)

✓ High fasting blood glucose (>100 mg/dl)

✓ Abdominal obesity (> 40 inches in men; > 35 inches in females)

✓ Elevated blood pressure (> 130/85 mmHg)

✓ Low High-Density Lipoproteins (<50 mg/dl)

Question 57

Assessment Criteria for TPN

Answer 57

The assessment criteria used to determine the need for total parenteral nutrition (TPN) include an inability to achieve or maintain enteral access. Examples include motility disorders, intractable diarrhea (Choice A), impaired absorption of nutrients from the gastrointestinal tract (Choice B), and when oral intake has been inadequate for a period over seven days. TPN promotes tissue healing and is an excellent choice for a patient with burns who has an improper diet. Please note that oral intake is the best feeding method; the second best method is via the enteral route. Total parenteral nutrition (TPN) is indicated only in specific cases. TPN provides calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. TPN can also promote tissue and wound healing and healthy metabolic function. TPN may be used to improve a patient’s response to surgery. TPN is a highly concentrated, hypertonic nutrient solution. Hence, it is given intravenously through a central venous access device, such as a multi-lumen, tunneled catheter into the subclavian vein, or a peripherally inserted central catheter (PICC). Strict surgical asepsis should be followed due to the risk of infections.

Question 58

Appendicitis Assessment

Answer 58

Pain in right lower quadrant
anorexia
increased WBC and temperature
Nausea
McBurney’s Sign/Psoas

Pain begins as dull, steady periumbilical pain that progresses over 4-6 hrs and localizes
sudden relief may indicate rupture, which increases risk for peritonitis

Question 59

Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 59

Endoscopic retrograde cholangiopancreatography (ERCP) has a procedure that has lost popularity in the years because of the risk of post-procedure pancreatitis. This procedure aims to examine the biliary tree for obstruction or inflammation.

➢ This procedure involves moderate sedation, which requires the client to be NPO for six to eight hours prior to the procedure

➢ The client may be repositioned during this procedure to enhance the visualization of the structures

➢ Abdominal cramping immediately following this procedure is likely because of the gastric insufflation of carbon dioxide

➢ The client should be educated on any signs of pancreatitis, which includes nausea, vomiting, and/or abdominal pain

➢ Other complications include infection, bleeding, or perforation

Question 60

immediate interventions for DKA

Answer 60

For a client with DKA, the immediate need should focus on restoring the depleted fluid volume caused by hyperglycemia (polyuria). Additionally, regular insulin intravenously is prescribed to correct the acidosis and hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia.

Question 61

treatment of DKA

Answer 61

potassium, insulin, NG tube, glucose, fluids, monitor creatinine and urea.

Question 62

manifestations of hyperthyroidism

Answer 62

Excessive thyroid hormones stimulate most body systems, causing hypermetabolism and increased sympathetic nervous system activity. This gives the client with hyperthyroidism the classic features such as tachycardia, increased body temperature, weight loss, diaphoresis, insomnia, elevated systolic blood pressure, and ocular symptoms such as an injected (reddened) conjunctiva.
✓ Graves’ disease is an autoimmune disease and is the most common cause of hyperthyroidism

✓ A hallmark finding of this disease is heat intolerance

✓ Other manifestations of hyperthyroidism include exophthalmos, weight loss, irritability, and the thinning of scalp hair

✓ The course of treatment is antithyroid medications (propylthiouracil or methimazole) or surgical intervention

Question 63

Clear Liquid Diet

Answer 63

Clear liquid diets consist of foods and liquids that are transparent to light and are liquid when at body temperature. This diet is best for patients who have not had oral intake for some time as well as for the first time a patient eats after complete bowel rest.

Question 64

Full liquid diet

Answer 64

This diet is appropriate as a transition after a clear liquid diet for patients following surgery, but should not be the first diet ordered.

Question 65

soft diet

Answer 65

this is only indicated when patients have difficulty chewing or swallowing and need foods that are much easier to eat.

Question 66

mechanical diet

Answer 66

This diet consists of foods that have been processed so that they do not require some or any chewing. It is used for patients with dental problems, surgeries to the head and neck, or other disorders that make chewing difficult or unsafe.

Question 67

which position should the patient be in after liver biopsy?

Answer 67

The client should lay on the right side with a pillow against the biopsy site at the right costal margin. Following the liver biopsy, the right lateral decubitus position reduces the risk of post-biopsy bleeding by putting pressure on the liver biopsy site.

Question 68

Function of the liver

Answer 68

• produces bile, albumin, and cholesterol
• converts glucose to glycogen for storage
• converts ammonia to urea for waste
• metabolizes bilirubin the breakdown of red blood cells
• metabolizes drugs and toxins
• regulates clotting factors

Question 69

Hirschprung’s disease

Answer 69

In Hirschsprung’s disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus.

Question 70

Gastric Analysis

Answer 70

he gastric analysis involves the insertion of a nasogastric tube (NGT) and aspiration of gastric contents for analysis of pH, appearance, and volume. The patient needs to be on NPO (nothing by mouth) for 8 – 12 hours before the test.

Question 71

Education for a client with diabetes

Answer 71

Client education for a patient with diabetes should include –

A diet with limited simple carbohydrates (refined sugars).
Blood glucose monitoring and medication administration.
Sick day rules.
Laboratory testing to surveil for complications such as diabetic nephropathy.
Annual vision exams.
Exercise to maintain a healthy weight and to prevent cardiovascular disease.

Question 72

corticosteroid Side effects

Answer 72

cataracts; up all night; suppressed immune system; hypertension; infection; necrosis; weight gain; striae; bone loss; acne; diabetes; myopathy; depression/mood changes

Question 73

Which vitamin should be added to a vegan diet?

Answer 73

Vitamin B12 is abundantly present in food products of animal origin. These include eggs, poultry, dairy products, fish, and meat. No strict vegetarian source has sufficient vitamin B12 to meet the recommended daily allowance (RDA). Vegans refrain from consuming all animal products, including eggs and dairy. Therefore, vegans are at a very high risk of developing vitamin B12 deficiency. Vegans should be counseled to consume alternative sources of vitamin B12 such as vitamin B12 supplements foods fortified with vitamin B12 ( fortified nutritional yeasts, fortified cereals) to reduce the risk of B12 deficiency significantly

Question 74

B-12 deficiency

Answer 74

Vitamin B12 deficiency can lead to fatigue, dementia, glossitis ( tongue inflammation), macrocytic anemia ( anemia with large red blood cells), pancytopenia ( reduced blood counts along all cell lines, i.e., reduced red cells, white blood cells, and platelets ), and neurological manifestations ( neuropathy, paresthesias. tingling and numbness in extremities). Vitamin B12 is abundantly stored in the body (up to 1000 times recommended daily allowance). Therefore, it generally takes several years of suboptimal b12 intake or poor absorption for vitamin B12 deficiency to develop. The population at risk for vitamin B12 deficiency include:\

Vegans who consume no animal or dairy products.
Exclusively breastfed infants of vegan women.
Clients with vitamin b12 malabsorptive conditions ( pernicious anemia, celiac disease, Crohn’s disease)
Clients with gastric bypass surgery or other surgeries where the stomach is removed.
Older adults
Long term use of proton pump inhibitors
Long term use of metformin

Question 75

Dumping syndrome

Answer 75

Dumping syndrome is a collection of symptoms that occur when the contents of the stomach empty too rapidly into the small intestine.
A large percentage of dumping syndrome cases are associated with gastric surgery, with an estimated 20-50% of clients who undergo surgery to remove or bypass the stomach (e.g., gastrectomy, gastric bypass surgery, gastric sleeve surgery, etc.) ultimately developing symptoms of dumping syndrome.
Rapid gastric emptying causes large amounts of undigested food to empty rapidly into the small intestine, causing the client to experience nausea, abdominal cramping, diarrhea, and/or rapid blood glucose responses.

Question 76

What vitamin increases the absorption of iron?

Answer 76

Vitamin C
Vitamin C increases the absorption of iron. Due to the vitamin C concentration in orange juice, consuming the iron supplement with orange juice would aid in the absorption of the iron supplement.

Iron is responsible for oxygen distribution to hemoglobin and myoglobin.
Iron is absorbed the best on an empty stomach. However, iron supplements can cause stomach cramps, nausea, and diarrhea in some individuals.
Some clients may need to take iron with a small amount of food to circumvent these problems.

Question 77

Addisonian Crisis

Answer 77

A client experiencing an adrenal crisis (Addisonian crisis) tends to have significant hypovolemia and hyponatremia. Because of the deficiency of steroid hormones, distributive shock may follow. Restoring the circulatory volume is essential in the management of this crisis. Isotonic solutions such as 0.9% saline or D5NS ( dextrose 5% in water combined with 0.9% saline) must be used. Isotonic saline can address both hypovolemia and hyponatremia in the adrenal crisis. If there is concomitant hypoglycemia, the D5NS solution is preferred to increase the glucose, sodium, and circulatory volume.
✓ Addison’s disease is an autoimmune condition in which the client has insufficient cortisol and aldosterone.

✓ The mainstay treatment is lifelong corticosteroid replacement with hydrocortisone.

✓ The dosage of replacement hormones may need to be increased if the client experiences increased demands from stressful events or illnesses.

✓ Failure to increase the replacement doses to meet the demand will result in an adrenal crisis and shock.

✓ During an adrenal crisis, the priority treatment is administering hydrocortisone intravenously.

✓ The client is often volume depleted, hypoglycemic, and hyponatremic and will need rapid fluid resuscitation.

✓ Dangerously high potassium levels ( hyperkalemia) are also evident in an adrenal crisis and require cardiac monitoring and potassium-reducing medications such as sodium polystyrene.

Question 78

which electrolyte imbalance can be expected with a gastro-jejunostomy tube?

Answer 78

There is a large amount of extracellular fluid in the peritoneal cavity, which contains a high amount of sodium. If this fluid is lost through the GJ tube, there will be a sodium deficit.

Question 79

what should be used to cleanse a fresh gastrostomy tube?

Answer 79

When caring for a new gastrostomy tube; the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage.
The site should be left open to air unless there is drainage. If drainage is present, one thickness of pre-cut gauze should be placed under the external bumper and changed as needed to keep the area dry.
Once sutures are moved, the external bumper can be rotated 90 degrees once daily.

Question 80

which acid-base imbalance would excessive vomitus cause?

Answer 80

Excessive vomiting would cause the discharge of hydrochloric acid and would therefore leave the client with more bicarbonate. This would put the client in an alkalotic state (pH greater than 7.45).

Question 81

Metabolic alkalosis

Answer 81

Metabolic Alkalosis is a condition in which the client eliminates more acid than bicarbonate. Common causes of metabolic alkalosis include excessive vomiting, diuretics, and suctioning from a nasogastric tube (NGT). Metabolic alkalosis is associated with hypokalemia, and thus, the nurse must watch for this effect.

Question 82

Correct Sequence of abdominal exam

Answer 82

For the abdominal exam, the exact sequence of actions would be inspection, auscultation, percussion, and palpation. The abdominal assessment is an integral part of the evaluation of any patient, but it is critical when the chief complaint is related to intestinal issues. The abdominal assessment should always progress from least intrusive (inspection) to most invasive. All findings should be related to one or more of the four quadrants of the abdomen. For example, a laceration noted in the right upper quadrant might be a documented finding.

During the abdominal assessment, the clinician should look at the stomach first, observing for swelling, lacerations or punctures, asymmetry, or other abnormalities. In the second step, auscultation, the clinician is listening for bowel sounds. It is essential to do this before palpation or percussion since any manipulation of the abdomen can change the bowel sounds. If bowel sounds are not immediately auscultated, the clinician should spend 30-60 seconds listening. Palpation should be gentle to determine the amount of discomfort the patient is having. When percussion is needed, it helps the nurse assess the borders of the major organs (especially the liver and spleen).

Question 83

TPN

Answer 83

TPN can cause hyperglycemia, so blood glucose levels should be closely monitored.

Parenteral nutrition, or intravenous feeding, is a method of getting food into the body through the veins. Depending on which thread is used, this procedure is often referred to as either total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN). Parenteral nutrition is used to help people who can’t or shouldn’t get their core nutrients from food. It’s often used for people with:

Irritable Bowel or Crohn’s disease
Cancer
Short bowel syndrome
Ischemic bowel disease
It also can help people with conditions that result from low blood flow to the bowels. Parenteral nutrition delivers nutrients such as sugar, carbohydrates, proteins, lipids, electrolytes, and trace elements to the body. These nutrients are vital in maintaining high energy, hydration, and strength levels. The most common side effects of parenteral nutrition are mouth sores, poor night vision, and skin changes. You should speak with your doctor if these conditions don’t go away.

Other less common side effects include:

changes in heartbeat
confusion
convulsions or seizures
difficulty breathing
fast weight gain or weight loss
fatigue
fever or chills
increased urination
jumpy reflexes
memory loss
muscle twitching, weakness, or cramps
stomach pain
swelling of your hands, feet, or legs
thirst
tingling in your hands or feet
vomiting

Question 84

Steatorrhea

Answer 84

Steatorrhea refers to the excretion of abnormal quantities of fecal fat due to reduced fat absorption by the intestines. This produces pale, oily, malodorous stools and is a symptom of Celiac disease.

Question 85

Diarrhea

Answer 85

Diarrhea refers to a condition in which feces are frequently discharged from the bowels and in a liquid form. It is not pale, oily, or malodorous stools.

Question 86

Hematochezia

Answer 86

Hematochezia is defined as the passage of fresh blood from the anus. It is a sign of lower GI tract bleeding. It is not pale, oily, or malodorous stools.

Question 87

Melena

Answer 87

Melena is a condition with dark sticky feces containing partly digested blood. Melena is a sign of gastrointestinal (GI) bleeding, often upper GI. Pale, oily, malodorous stools do not characterize melena; rather, it is typical with steatorrhea.

Question 88

Positive McBurney’s sign

Answer 88

A positive McBurney’s sign is indicated when there is significant pain upon palpation of this area in
the right lower quadrant.
* Begins as dull, steady
periumbilical pain * Over 4-6 hours, pain progresses and localizes to
right lower quadrant (RLQ) * Sudden relief of pain may indicate appendix rupture
(which can lead to peritonitis)

Question 89

Dietary needs for hyperlipidemia

Answer 89

Red meats are rich in saturated fat. It should be eaten less frequently because it contributes to high cholesterol levels.
Replacing vegetable oils high in polyunsaturated fats with canola oil (monounsaturated fats) is more beneficial in reducing cholesterol levels.
Fish like tuna and salmon are rich in omega 3 fatty acids, which help in reducing harmful cholesterol levels.
Fruits and vegetables contain fiber, which promotes a healthy cholesterol level.

Question 90

NG tube medication administration considerations

Answer 90

The air vent should not be irrigated with water or used to administer medications. The purpose of the air vent is to permit free, continuous drainage of secretions when the NGT is connected to suction. This vent is found on a Salem sump tube and is often called a blue “pigtail.”
Fragments of medication may clog an NGT, and medications interchanged into a liquid form are preferred to prevent this obstruction. Medications should be administered individually to prevent medications from reacting with each other and causing obstruction in the tubing. Flushing the tube with 15-30 mL of water in between each medication is essential to prevent obstruction of the tubing.
✓ After the placement of an NGT, the nurse should verify the placement via an x-ray

✓ Subsequent verification should come through gastric pH analysis. A pH < 4 indicates the tube is likely in the stomach.

✓ When administering medications via NGT, the nurse should never crush extended-release or sustained-release medications.

✓ To administer medications via NGT, the nurse should disconnect the NGT suctioning.

✓ The nurse should initially flush the NGT with 20-30 mL of tepid tap water.

✓ The nurse should flush the tube with 15 mL between each medication.

✓ Once the medications have been administered, the nurse should flush the NGT with 20-30 mL of tepid tap water.

Question 91

Salem Sump and Levin sump NG tubes

Answer 91

✓ The Levin and Salem sump tubes are the most common for stomach decompression.

✓ The Levin tube is a single-lumen tube with holes near the tip

✓ The Salem sump tube is preferable for stomach decompression. The tube has two lumina: one for removal of gastric contents and one to provide an air vent.

Question 92

Home Teaching for GERD

Answer 92

Small, frequent meals are an excellent recommendation to help alleviate GERD symptoms. This will ensure the stomach does not overfill and helps to decrease the amount of reflux the patient is experiencing.
The upright position is very important for GERD patients while they are eating. This is good education. Upright positioning will help to prevent or decrease the passage of gastric contents into the esophagus.

Question 93

Girth Landmarking

Answer 93

With ascites, free fluid accumulates primarily in the abdominal cavity. As liver dysfunction worsens, ascites typically increase, increasing the abdominal girth. When measuring abdominal girth, standard practice dictates using the umbilicus as the landmark to be utilized when measuring a client’s abdominal girth. The technique involves encircling the abdomen with a measuring tape at the level of the umbilicus. Using this method, you ensure the client’s future measurements are accurate and comparable to prior measurements, even if performed by other clinicians.

Question 94

Intusessception

Answer 94

Red, currant jelly-like stools are a characteristic of intussusception and are a result from a mixture of stool, blood, and mucus.
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a behavioral pain assessment scale used for nonverbal or preverbal clients (i.e., pediatric, cognitively delayed, etc.) who are unable to self-report their level of pain.
Intussusception generally occurs between 6 months and three years of age.
In children less than four years of age, intussusception is much more common in males (8:1).
The cause of intussusception usually is unknown.
Children typically present with colicky abdominal pain and vomiting, followed by passage of red, currant-jelly stool.
Treatment is reduction by air enema and, if required, surgery.

Question 95

What kind of bleed does black tarry stools indicate

Answer 95

Black, tarry stools are indicative of upper gastrointestinal bleeding.

Question 96

what kind of stools does Hirschprung’s Disease produce?

Answer 96

Ribbon-like stools may occur in some clients with Hirschsprung disease.

Question 97

What type of stools are expected in patients with cystic fibrosis?

Answer 97

Greasy, foul-smelling stools are a characteristic stool pattern for clients with cystic fibrosis.

Question 98

Primary Cushing’s Disease Characteristics

Answer 98

Primary Cushing’s disease is characterized by hypersecretion of ACTH from the pituitary gland, which is usually due to a pituitary adenoma. This causes the client to experience multisystem manifestations such as sodium and water retention leading to weight gain, elevated blood glucose, delayed wound healing, and increased gastric acid secretion.
Hypercortisolemia in Cushing’s disease is usually due to corticotropin (ACTH)-producing pituitary tumor (Cushing’s disease), ectopic ACTH secretion by a nonpituitary tumor, or cortisol secretion by an adrenal adenoma or carcinoma. Clinical features of Cushing’s disease include sodium and water retention, weight gain, fatigue, hyperglycemia, truncal obesity, and sexual dysfunction.

Question 99

Considerations for patient receiving continuous insulin infusion

Answer 99

Close blood glucose and potassium monitoring are essential for the client receiving a regular insulin infusion. Because insulin shifts glucose and potassium into the cells, the most common complications of regular insulin therapy are hypoglycemia and hypokalemia. Clinical manifestations of hypokalemia include –

Confusion
Muscle weakness
Shallow respirations
Abdominal distention
Hypotension and weak pulse
Nausea and vomiting

Question 100

Which diet should be expected for an individual who practices Orthadox Judaism

Answer 100

As outlined in the Torah, clients who practice Orthodox Judaism typically consume a kosher diet. Although a few dietary laws are associated with Orthodox Judaism (and discussed below), one of the key aspects required when following a kosher diet is avoiding consuming meat and dairy products in the same meal. Here, offering your client a cottage cheese salad with fresh fruit is acceptable, as the meal does not violate any kosher dietary laws.
The Torah provides the dietary laws for Orthodox Judaism.
Most clients who practice Orthodox Judaism do not eat meat with dairy products in the same meal.
Orthodox Judaism prohibits food preparation on the Sabbath.
Clients who follow Orthodox Judaism typically only consume fish that have scales and fins.
Orthodox Judaism only allows for the consumption of Kosher animals.
Following this practice, specific regulations specify how animals are slaughtered, specifically so that no blood is consumed.

Question 101

An indivvidual who is post-op colon resection with placement of colostomy is most at risk for…

Answer 101

Immediately postoperative clients run the risk of airway, breathing, and circulation compromise. Surgeries often result in a client losing volume and may cause intraoperative and postoperative bleeding. The nurse must be aware that an increased heart rate and low blood pressure are classic indicators of fluid volume deficit, which, if untreated, may cause the client to develop hypovolemic shock. Hypovolemic shock may be caused by hemorrhage, a significant concern immediately post-operative.

Question 102

Appendicitis Manifestations

Answer 102

✓ Appendicitis is an emergency that features pain in the right lower quadrant, nausea and vomiting, fever, leukocytosis, and anorexia.
✓ Appendicitis may be caused by obstruction, leading to inflammation and pressure.
✓ Nursing care for appendicitis includes –
Maintaining nothing by mouth (NPO) status.
Initiating an intravenous (IV) catheter.
Administering prescribed antibiotics and IV fluids.
Preparing the patient for surgery.
The client should be monitored for perforation, which may manifest as abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees.

Question 103

Peritonitis

Answer 103

Peritonitis is an intra-abdominal severe infection that has a significant mortality rate. Peritonitis may originate from perforation (appendix, intestine, etc.), which causes a significant amount of fluid and bacteria to shift into the peritoneum. The priority treatment in peritonitis is administering prescribed antibiotics such as ciprofloxacin, metronidazole, or ceftriaxone.

Clinical manifestations of peritonitis include
✓ Rigid, board-like abdomen
✓ Distended abdomen
✓ High fever
✓ Tachycardia
✓ Diffuse abdominal pain that continues to intensify
✓ Decreased bowel sounds and GI motility

Question 104

Why should TPN always be titrated down?

Answer 104

Abrupt discontinuation of total parenteral nutrition (TPN) may lead to severe hypoglycemia, and for this reason, the infusion must be decreased gradually. Additionally, the client should have glucose assessments performed at intervals specified by the health care provider (HCP) both during the weaning of the TPN and in the immediate aftermath of the weaning process.

Question 105

Which imbalance would the nurse monitor for a client with fluid imbalance related to the development of ascites

Answer 105

Ascites indicates fluid accumulation in the peritoneal cavity. It is easy to get confused that these clients are in a state of overall fluid volume excess, however, these clients are prone to hypotension due to circulatory volume deficit. The “effective” circulatory volume refers to the portion of the extracellular fluid (ECF) present in the vascular compartment and actively perfuses the tissues. ECF is a sum of plasma volume and interstitial fluid volume. Patients with fluid shifts due to ascites are at risk for “effective” ECF deficit, protein deficit (hypoalbuminemia), sodium deficit, and plasma-interstitial fluid shift. ECF is not just confined to interstitial fluid volume. ECF is subdivided into two compartments - blood plasma and interstitial fluid. While interstitial fluid increases in ascites due to fluid shifts, there is a decrease in the circulatory volume or effective ECF volume. Therefore, the cirrhotic clients with ascites are prone to hypotension. The nurse must recognize that these clients are at risk of hypotension because their “effective” circulatory ECF is actually in deficit. In cases where indicated, albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and transiently improving the blood pressure.

Hypoalbuminemia occurs in liver cirrhosis because of the failure of synthetic function of the liver. Low albumin causes low oncotic pressure. This low osmotic pressure along with increased hydrostatic pressure within the vascular compartment ( portal hypertension) in liver cirrhosis leads to fluid moving from vascular compartment to peritoneal cavity ( ascites).

Sodium deficit is seen as “dilutional” hyponatremia in liver cirrhosis because more water is retained relative to the sodium.

Question 106

Hypothyroidism labs

Answer 106

✓ Hypothyroidism labs show low T4 and elevated TSH

Question 107

Hypothyroidism Education

Answer 107

When discharging a pediatric patient who is newly diagnosed with hypothyroidism, it is essential to educate the parents about how to administer thyroid medication. Taking thyroid medication in the evening can cause insomnia. It should be taken at the same time each day, on an empty stomach, 30 minutes before breakfast. Constipation is common in hypothyroidism, so it is important to educate on the importance of increasing fluids and fibrous foods.

Question 108

Diabetic Foot Care Education

Answer 108

Due to the deficit in nerve sensation, some diabetic patients may not feel the ache of a blister or the sting of a cut on their feet. Vascular changes in diabetic patients may cause decreased perfusion of the tissues in the feet. If a wound of any type occurs, it may be slower to heal. Therefore, prevention is the best tool to protect a diabetic patient. It is important that the nurse teach diabetic foot care and ensure that the client has a clear understanding of the risks associated with poor foot care.

The patient should be taught to check his feet daily for any signs of blisters, sores, or dryness, which can cause cracking (Choice A). The patient should keep the feet dry and this will prevent chafing from moisture (Choice B). A blister or sore should never be opened. If opened it may create a non-healing open wound because the healing time for a diabetic patient is often delayed (Choice C).
Thin creams or lotions can be applied on the tops and bottoms of feet to keep the feet soft and prevent cracking. However, creams should not be applied between the toes because it promotes moisture, which can lead to chafing, blisters, and open wounds. Moisture between toes may also predispose to fungal infections. Instead, the skin between the toes should be kept dry by sprinkling talcum powder or cornstarch between the toes.
Compression socks may be used to reduce edema in the lower extremities, but the use of tight compression socks is not appropriate for diabetic clients as they can restrict blood flow. Instead, diabetic clients should be instructed to wear clean, loose socks with closed toe shoes that fit well.

Question 109

The nurse is teaching a client about diabetes mellitus. Which of the following information should the nurse include?

Answer 109

A client with diabetes mellitus should be advised to have annual eye examinations because of the risk of diabetic retinopathy. Finally, the nurse should emphasize the client checks their blood glucose for any symptoms of HYPOglycemia such as palpitations, drowsiness, and feeling shaky.

An individual with diabetes mellitus will require extensive teaching by the nurse. The teaching will include blood glucose monitoring, diet, follow-up lab work, foot care, and medications. A client’s hemoglobin A1C should be monitored closely as an increase indicates multiple episodes of HYPERglycemia.

Question 110

Esomeprazole

Answer 110

Esomeprazole is a proton pump inhibitor (PPI) in treating esophageal erosion, GERD, and peptic ulcer disease. The medication should be taken one hour before meals and with an ample amount of water. The medication does not fortify an existing ulcer, like sucralfate. The client does not require frequent laboratory testing while on this medication.
✓ PPIs are the gold standard in the treatment of GERD.
✓ Medications in this class include esomeprazole, pantoprazole, and lansoprazole.
✓ The client should be instructed to take the medication first thing in the morning without food or other medications.
✓ The long-term use of a PPI has been linked to osteoporosis and hypomagnesemia. Therefore, it is reasonable to recommend weight-bearing exercises and magnesium and calcium supplements approved by the primary healthcare provider (PHCP).

Question 111

Immediate Treatment for Adrenal Crisis

Answer 111

An adrenal crisis is a medical emergency for both an adult and a child. Remember, you need to add the treatment in an adrenal crisis (Addisonian crisis). The immediate treatment for a client in an adrenal crisis is replacing the corticosteroid via intravenous (IV) hydrocortisone. The treatment goal of administering IV hydrocortisone is to increase the low glucose levels and retain some of the fluid and sodium. The second essential treatment is administering IV fluids of 5% dextrose with 0.9% saline. The 5% dextrose with 0.9% saline will raise the glucose (D5) and circulating volume (0.9% saline). Giving D5W alone would be detrimental as the water will lower serum sodium levels.
✓ An adrenal crisis is a medical emergency causing severe dehydration, hyponatremia, hypoglycemia, and hyperkalemia
✓ The crisis may be triggered by a sudden cessation of corticosteroids or Addison’s disease that is unresponsive to the need for an additional steroid because of a stressful event (dental work, illness, etc.)
✓ Adults and children may experience this medical emergency
✓ The priority treatment is IV hydrocortisone
✓ The nurse should also be prepared to administer IV fluids (Dextrose 5% with 0.9% saline) or 0.9% saline
✓ The IV fluids are necessary to restore circulatory volume and increase serum glucose
✓ Cardiac monitoring should be established because this crisis features significant hyperkalemia
✓ Treatment would include regular insulin intravenously and sodium polystyrene
✓ Fall precautions should be implemented because the client is dehydrated and may develop orthostatic hypotension

Question 112

Signs and symptoms of hyperglycemia

Answer 112

Blurred vision: hyperglycemia causes alteration of the eye lens, which explains the blurred vision.
Polyuria: Increased urine output due to glycosuria. Glycosuria causes osmotic diuresis - glucose in the urine pulls excessive water with it, resulting in significant water losses and subsequent dehydration.
Tachycardia: increased heart rate from the diuresis leading to dehydration.
Orthostatic hypotension: Postural (orthostatic) hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg or more and diastolic blood pressure of at least 10 mm Hg or more within two to five minutes of quiet standing after five minutes of supine rest.
Symptoms of hyperglycemia include increased thirst (polydipsia), polyuria, polyphagia, weight loss, blurry vision, and slow wound healing. Long-standing hyperglycemia can lead to nerve damage resulting in neuropathy (tingling, numbness, neuropathic pain). Hyperglycemia leads to osmotic diuresis when glucose levels are so high that glucose is excreted in the urine. Water follows the glucose concentration passively, leading to abnormally high urine output. In turn, this leads to dehydration. Dehydration manifests with tachycardia because the body responds to maintain perfusion by increasing cardiac output. Dehydration results in hypovolemia, which may present with orthostatic hypotension.

Question 113

Causes of hypoglycemia

Answer 113

Hypoglycemia may be caused by –
Inappropriate dosing of insulin or antidiabetics such as glipizide
Insulin and mealtime mismanagement (example – rapid-acting insulin given when the patient is NPO or given too early prior to a meal)
Inappropriate dosing of insulin
Exercise or the consumption of alcohol

Question 114

Treatment for hypoglycemia

Answer 114

Treatments for hypoglycemia include 15 grams of quick-acting carbohydrates and rechecking the blood glucose within 15 minutes. If the patient is lethargic, do not feed the client and consider prescribed treatments such as dextrose 50% or glucagon.

Question 115

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)?

Answer 115

Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia’s gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels.

Treatment options for hepatic encephalopathy would include prescribed potassium-sparing diuretics, lactulose, and antibiotics such as neomycin or rifaximin. Nursing care aims to assist the client in achieving and maintaining treatment adherence and the avoidance of medication such as NSAIDs and benzodiazepines that could worsen the encephalopathy.

Question 116

Foods high in fibre

Answer 116

Fruits and vegetables (with skins, when possible): Apples, strawberries, pears, carrots, corn, potatoes with skins, and broccoli
Whole grains and whole grain products: Whole wheat bread, bran muffins, bran cereals, oatmeal, brown rice, and whole-wheat pasta
Legumes: Peas, lentils, kidney beans, lima beans, baked beans, and nuts

Question 117

Cushing’s Disease symptoms

Answer 117

Primary Cushing’s disease is characterized by hypersecretion of ACTH from the pituitary gland, which is usually due to a pituitary adenoma. This causes the client to experience multisystem manifestations such as sodium and water retention leading to weight gain, elevated blood glucose, delayed wound healing, and increased gastric acid secretion. Hypercortisolemia in Cushing’s disease is usually due to corticotropin (ACTH)-producing pituitary tumor (Cushing’s disease), ectopic ACTH secretion by a nonpituitary tumor, or cortisol secretion by an adrenal adenoma or carcinoma. Clinical features of Cushing’s disease include sodium and water retention, weight gain, fatigue, hyperglycemia, truncal obesity, and sexual dysfunction.

Question 118

Treatment for hypokalemia secondary to DKA

Answer 118

Insulin

Question 119

DKA

Answer 119

DKA is a common complication associated with type one diabetes mellitus. DKA may cause both hyperglycemia and hypovolemia.
Treatment for hyperglycemia includes the initiation of a prescribed regular insulin bolus at 0.1 unit/kg followed by a continuous infusion at 0.1 unit/kg/hr. This treatment will also target the acidosis found with DKA.
Treatment for hypovolemia includes the initiation of isotonic saline infusions at 15 to 20 ml/kg during the first hour. Fluid volume treatment has been effective when urine output restores to normal, the heart rate is within normal limits, and the client is normotensive.
For the client receiving regular insulin, close monitoring of their blood glucose and potassium is essential. The most common complications of regular insulin therapy are hypoglycemia and hypokalemia.

Question 120

Diverticulosis dietary needs

Answer 120

Diverticulosis is a condition in which the client develops small herniations in the large bowel. A common cause of this condition is a low-fiber diet. The client is instructed to increase their fiber and water intake as these measures are key in promoting bowel motility. If the client should develop diverticulitis, the prescribed diet is NPO (nothing by mouth) status and slowly advanced to clear liquids.

Question 121

The nurse is providing discharge instructions to a client who has chronic diabetes insipidus (DI). Which of the following client statements would indicate a correct understanding of the discharge instructions?
A. “I will need to drink no more than 800 ml per day.”
B. “I will need to weigh myself at the same time every day.”
C. “I should increase salty snacks in my diet.”
D. “I need to log my daily fluid intake.”

Answer 121

A client with chronic diabetes insipidus (DI) must weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Weight is the most accurate assessment relevant to fluid volume status.
✓ DI is a condition that may be central or nephrogenic

✓ The nurse must teach the client about the treatment plan, which will involve the replacement of antidiuretic hormone via vasopressin or desmopressin

✓ The client is at risk for fluid volume deficit because the client may experience polyuria

✓ This may manifest as tachycardia, hypotension, thready pulse, and hypernatremia because the urine output is pale and mostly comprised of water

Question 122

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus?

Answer 122

Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI).

Question 123

Which foods should ostomy clients avoid due to their foul-smelling nature in the GI tract?

Answer 123

Eggs, asparagus, alcohol, fish, onions, cabbage, and grapes are just a small sampling of the foods known to cause foul-smelling stools, gas, and/or increased foul odors, which ostomy clients often report as concerning. These clients should be educated and provided with a comprehensive list of foods to avoid to reduce the likelihood of omitting foul odors from their ileostomy.
When a client undergoes an ileostomy, a loop of the client’s ileum is placed through an opening in the abdominal wall (i.e., stoma), allowing drainage of fecal material into a pouching system positioned on the abdomen.
Cranberry juice also relieves gas and odor in clients with an ileostomy.
The intake of excess air may cause gas and subsequent odor. Therefore, the client should refrain from chewing gum, consuming meals too quickly, and/or drinking through a straw.
Odor-resistant pouches, special deodorant liquids, and/or tablets indicated for pouch placement are available to address ostomy-related odor concerns if the client chooses.

Question 124

Teaching for Addison’s Disease

Answer 124

Medication adherence to the prescribed corticosteroid
Dietary management involves adequate sodium and reducing potassium
Self-monitoring of weight and blood pressure
Notifying the primary healthcare provider of any stressful events or illnesses which may trigger a crisis
Wear a medical alert ID bracelet or tag
Keep a dose of emergency hydrocortisone at all times, and know when and how to administer the injection
Understand and be alert for the signs of an Addisonian crisis (profound fatigue, dizziness, abdominal cramping, confusion)

Question 125

risk factors for sensorineural hearing loss

Answer 125

Impairments of the nerve fibers cause sensorineural hearing loss. Causes of this type of hearing loss include prolonged exposure to noise, ototoxic substances (aminoglycosides), diabetes mellitus, and presbycusis (age-related hearing loss). This type of hearing loss is often not reversible.

Question 126

risk factors for conductive hearing loss

Answer 126

Conductive hearing loss is caused by obstruction. Causes of this type of hearing loss include cerumen, foreign body, water, edema, infection, or tumor. This type of hearing loss may be reversible.

Question 127

Hypercalcemia dietary needs

Answer 127

Hypercalcemia can occur in various conditions such as primary hyperparathyroidism, malignancies, milk-alkali syndrome, medications, vitamin D toxicity, and sarcoidosis. Symptomatic hypercalcemia can lead to constipation, psychosis, polyuria, and dehydration. Clients with hypercalcemia should take some dietary precautions to reduce calcium intake. Broccoli is rich in calcium and should therefore be avoided in clients with hypercalcemia. Milk is rich in calcium and should therefore be avoided in clients with hypercalcemia.

Question 128

treatment for mild hypoglycemia

Answer 128

For mild hypoglycemia (hungry, irritable, shaky, weak, headache, fully conscious; blood glucose usually less than 70 mg/dL [3.9 mmol/L]):

• Treat the symptoms of hypoglycemia with 15 g of carbohydrates. * Glucose tablets or glucose gel (dosage is printed on the package) * A half-cup (120 mL) of fruit juice or of regular (nondiet) soft drink * 8 ounces (240 mL) of skim milk * 1 tablespoon (15 mL) of honey or syrup * Retest blood glucose in 15 minutes.

Question 129

treatment for moderate hypoglycemia

Answer 129

For moderate hypoglycemia (cold, clammy skin; pale; rapid pulse; rapid, shallow respirations; marked change in mood; drowsiness; blood glucose usually less than 40 mg/dL [2.2 mmol/L]):

• Treat the symptoms of hypoglycemia with 30 g of rapidly absorbed carbohydrates. * Retest glucose in 15 minutes. * Repeat treatment if glucose is less than 60 mg/dL (3.4 mmol/L).

Question 130

Treatment for severe hypoglycemia

Answer 130

For severe hypoglycemia (unable to swallow; unconsciousness or convulsions; blood glucose usually less than 20 mg/dL [1.0 mmol/L]):

• Treatment administered by family members: * Give a prescribed dose of glucagon as an intramuscular or subcutaneous injection. * Give a second dose in 10 minutes if the person remains unconscious and call 911.

If the client is hypoglycemic and lethargic, the nurse should exercise good clinical judgment, administer parenteral treatment, and not risk aspiration by having the client eat/drink

Question 131

Gastroparesis

Answer 131

Gastroparesis is a finding associated with various conditions, including diabetes mellitus. This disorder causes the client to have abdominal fullness, nausea, vomiting, and weight loss. Treatment is aimed at increasing gastrointestinal motility by using agents such as metoclopramide or erythromycin. Dystonic reactions adversely occurring with metoclopramide may be treated with diphenhydramine or benztropine.

Question 132

The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?

A. Decreased abdominal cramping
B. Absence of nausea and vomiting
C. Decreased urinary retention
D. Less burning with urination

Answer 132

Dicyclomine is an antispasmodic agent used in the treatment of irritable bowel syndrome (IBS). This may provide the client with relief from the spasms and cramping associated with IBS.
✓ Dicyclomine is typically dosed on a PRN basis for a client experiencing abdominal cramping.

✓ This medication is antispasmodic and is often utilized for irritable bowel syndrome (IBS).

✓ The client should be educated on the common adverse effect of dizziness which may increase a client’s risk for falls.

Question 133

The nurse is preparing a client with peptic ulcer disease for a barium study of the stomach and esophagus. What should be the initial nursing action?

Answer 133

A side effect of barium is constipation after the procedure. The nurse, therefore, needs to instruct the client to drink lots of fluids. It is not, however, the initial intervention of the nurse.

Question 134

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer?

Ulcerative colitis

Body Mass Index (BMI) of 21

Human Immunodeficiency Virus (HIV) infection

Low-fiber diet

Excessive alcohol consumption

African-American ethnicity

Answer 134

Inflammatory bowel disease (especially ulcerative colitis) is a non-modifiable risk factor that may cause cellular damage and hasten the risk of colorectal cancer.
A diet low in fiber is a modifiable risk factor for colon cancer. Encourage the client to increase fiber intake and decrease red meat.
Excessive alcohol intake is a modifiable risk factor for colorectal cancer.
African American ethnicity is a non-modifiable risk factor for colorectal cancer.
Risk factors for colorectal cancer are divided into modifiable and non-modifiable types.

✓ Modifiable risk factors are usually behavioral factors that can increase a person’s risk of cancer. In theory, these risk factors can be modified with interventions.

✓ Non-modifiable risk factors are those that can not be changed. Awareness of the client’s risk factors will help the healthcare provider prescribe personalized lifestyle and cancer screening recommendations.

✓ The gold standard of colorectal cancer prevention is a colonoscopy that should begin as early as age 45

Question 135

Lactose Intolerance

Answer 135

Lactose is a sugar found most significantly in dairy products ( milk and cheese). The lactase enzyme in the small intestine is responsible for breaking down and digesting lactose. However, some individuals may have a lactase enzyme deficiency, causing them not to digest and absorb lactose ( lactose malabsorption). In some patients, lactose malabsorption leads to intolerance.

Undigested lactose in the intestine causes osmotic diarrhea, bloating, and flatulence. This constellation of symptoms is referred to as lactose intolerance.
While lactose malabsorption causes lactose intolerance, it is essential to remember that not all people with lactose malabsorption have lactose intolerance. Lactose intolerance is more common in patients with a family history of lactose intolerance, certain ethnic and racial groups ( Asian-Americans, African-Americans, Hispanics, and American Indians). It is uncommon in Europeans.
Individuals with lactose intolerance often avoid dairy products, which is a primary dietary source of vitamin D. Therefore, significant risks of lactose intolerance are generally the complications resulting from vitamin D and calcium deficiencies.

Question 136

Ulcerative Colitis

Answer 136

Ulcerative colitis is an inflammatory bowel disorder that may cause an individual to have classic colicky abdominal pain that may produce multiple bloody stools. This, in turn, may cause an individual to become dehydrated and anemic. Nursing care is aimed at symptom management and providing prescribed medications such as steroids during exacerbations and immunomodulators to reduce flares.

Question 137

Appendicitis

Answer 137

✓ Appendicitis is an emergency that features pain in the right lower quadrant, nausea and vomiting, fever, leukocytosis, and anorexia.

✓ Appendicitis may be caused by obstruction, leading to inflammation and pressure.

✓ Nursing care for appendicitis includes –

Maintaining nothing by mouth (NPO) status.
Initiating an intravenous (IV) catheter.
Administering prescribed antibiotics and IV fluids.
Preparing the patient for surgery.
The client should be monitored for perforation, which may manifest as abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees.

Question 138

The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question?

A. Levothyroxine for a client with a myxedema coma
B. Hydrochlorothiazide for a client with hyperparathyroidism
C. Hydrocortisone for a client with adrenal insufficiency
D. Regular insulin for a client with diabetic ketoacidosis

Answer 138

Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hydrochlorothiazide is a thiazide diuretic and causes the retention of calcium. This would be detrimental for a client experiencing hypercalcemia. This prescribed medication requires follow-up with the prescribe
Hyperparathyroidism is a disorder in which parathyroid secretion of parathyroid hormone is increased, resulting in hypercalcemia (excessive serum calcium levels) and hypophosphatemia (inadequate serum phosphorus levels).

Diuretic and hydration therapies help reduce serum calcium levels. Furosemide, a diuretic that increases kidney excretion of calcium, is used along with IV saline in large volumes to promote calcium excretion.

Question 139

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake?
A. Choose french fries over a baked potato
B. Select a cheeseburger over a regular hamburger
C. Pick sandwiches instead of wraps
D. Breaded chicken is a better choice than broiled

Answer 139

Teaching the adolescent about nutrition can be a challenge for nurses. It is essential to establish an accepting, relaxed atmosphere and show a willingness to listen to the teenager’s concerns. The nurse should keep suggestions to a minimum and focus on only the most important changes. If an adolescent believes she must eliminate all her favorite foods, she is likely to rebel.

Although not a popular choice for its nutritional value, strategic ways to optimize the intake of fast food include

Add cheese to hamburgers to increase calcium and protein. Include lettuce and tomato for vitamins A and C.
Avoid dressings on hamburgers because they tend to be high in calories and fat.
To reduce fat and calories, choose broiled, roasted, and barbecued foods (e.g., chicken breast, roast beef).
Avoid fried foods (e.g., French fries, fried zucchini, onion rings, fried cheese) because they are high in fat and the high heat may destroy some vitamins.
Breaded foods such as chicken nuggets and breaded clams are high in calories and absorb more oil if they are fried.
Try wraps instead of sandwiches to decrease calories.
Baked potatoes with broccoli, cheese, and meat fillings provide better nutrition than French fries.
Milk, milkshakes, and orange juice provide more nutrients than carbonated beverages, which are high in sodium and calories.
Avoid pickles, olives, and other salty foods. Too much sodium may increase swelling of the ankles.
Add only small amounts of salt to foods to prevent or decrease swelling.

Question 140

The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance?

Answer 140

Sodium polystyrene is a medication that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. Regular insulin is a standard and effective treatment for hyperkalemia. The standard dose is ten units given by intravenous push. Hemodialysis is an appropriate treatment for hyperkalemia. Hemodialysis can remove potassium from the blood.

Question 141

The nurse is caring for a patient following the placement of a gastrostomy tube. The Unlicensed Assistive Personnel (UAP) reports that the patient has thin, pale, and yellow-green drainage with a sour odor and a small amount of blood. Which is the best action for the nurse to take?

Answer 141

The nurse should assess the patient’s drainage to confirm it is within reasonable expectations for the patient’s condition. Up to 1500 mL/day of thin, pale, yellow-green drainage with sour odor and a small amount of blood would be expected for this patient.

Question 142

Celiac Disease

Answer 142

Celiac disease is a disease characterized by gluten intolerance. Exposure to gluten products causes the client to experience significant gastrointestinal symptoms, including vomiting, diarrhea, irritability, and muscle wasting because of the malabsorption of essential nutrients.
✓ Celiac disease is also known as gluten enteropathy or celiac sprue

✓ The client has an intolerance to gluten which is primarily found in barley, rye, oats, and wheat

✓ The condition is caused by intestinal villous atrophy, which causes malabsorption of ingested nutrients

✓ The onset of the disease is between the ages of 1 and 5 years

✓ Nursing care is directed at providing education regarding the avoidance of gluten foods

✓ A multivitamin is often prescribed

✓ Foods allowed in a gluten-free diet include beef, pork, rice, and cornflakes

Question 143

The nurse plans a staff developmental conference on total parenteral nutrition (TPN). It would be appropriate for the nurse to identify which indications for using TPN?
A. Appendicitis
B. Gastroesophageal reflux disease (GERD)
C. Diverticulosis
D. Pancreatitis

Answer 143

Pancreatitis is a condition that is triggered by cholelithiasis or acute alcoholism. This condition causes severe epigastric pain, persistent vomiting, and fluid volume depletion. The client with pancreatitis will require TPN because of the length of time it takes for recovery and the need for the client to stay NPO. TPN provides the client with nutrition without worsening the pancreatitis symptoms.
✓ TPN is a risk factor for infection as the high glucose content makes the client more likely to develop a bacterial or fungal infection

✓ During an infusion of TPN, the nurse should monitor the client’s vital signs and blood glucose

✓ Hyperglycemia may delay healing and should be managed with a prescribed insulin protocol

Question 144

NG tube considerations

Answer 144

Each medication should be given separately because mixing all the medications together could cause interactions. Verifying placement of the NGT before medication administration is an appropriate action. If the gastric pH is less than 5, the tube tip is in the stomach. It is preferred that liquid medications instead of crushed tablets should be administered. If crushed tablets are given, flush the tubing before and after the medication administration to prevent the medication from adhering to the inside of the tube.
✓ After the placement of an NGT, the nurse should verify the placement via an x-ray

✓ Subsequent verification should come through gastric pH analysis. A pH < 5 indicates the tube is likely in the stomach.

✓ When administering medications via NGT, the nurse should never crush extended-release or sustained-release medications.

✓ Once the medications have been administered, the nurse should flush the NGT with 20-30 mL of tepid tap water.

Question 145

During shift change, a nurse receives report regarding a client with ulcerative colitis, learning the client has experienced severe diarrhea over the past 24 hours. When assessing the client, the nurse should watch for signs of:

Answer 145

The nurse should watch for signs of metabolic acidosis, as diarrhea is one of the conditions most commonly associated with this acid-base imbalance due to bicarbonate loss occurring with diarrhea. Symptoms and signs of metabolic acidosis are primarily those of the underlying cause (i.e., here, the client’s diarrhea). More severe acidemia (i.e., pH < 7.10) may cause nausea, vomiting, and malaise.
Treatment of metabolic acidosis is based on the cause of the metabolic acidosis.
Ulcerative colitis is a chronic inflammatory and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea.
Extraintestinal symptoms, particularly arthritis, may occur.
Long-term risk of colon cancer is elevated compared to unaffected people.
Diagnosis is by colonoscopy.
Treatment occurs with various medications (i.e., 5-aminosalicylic acid, corticosteroids, immunomodulators, biologics, and/or antibiotics) and surgery in some clients.

Question 146

Acute Graft Liver Rejection

Answer 146

Acute graft rejection is a concern for a client who had a liver transplant. This complication commonly occurs from the 4th to the 10th postoperative day. While this client is only 48 hours postoperative, the rising AST/ALTs are concerning because this is a manifestation of acute graft rejection. Other manifestations of acute graft rejection include tachycardia, fever, right upper quadrant (RUQ) or flank pain, diminished bile drainage or change in bile color, or increased jaundice.
✓ Occurs from the 4th to 10th postoperative day

✓ Manifestations of this serious complication include tachycardia, fever, right upper quadrant (RUQ) or flank pain, diminished bile drainage or change in bile color, or increased jaundice

✓ Laboratory findings indicating acute graft rejection include increased levels of serum bilirubin, transaminases, and alkaline phosphatase; prolonged prothrombin time

Question 147

The nurse has administered prescribed five units of regular insulin and ten units of NPH insulin. The nurse anticipates that the soonest this insulin will peak will be within

Answer 147

This client was administered regular insulin that peaks within two to four hours. Additionally, this client received NPH insulin which peaks within four to twelve hours. It would be appropriate for the nurse to assess the client for hypoglycemia when the regular insulin peaks as it peaks sooner.

Question 148

The nurse is educating a new graduate about alterations in cortisol levels. Which of the following conditions does she explain cause an increased cortisol levels in a client?

A. Addison’s disease
B. Congestive heart failure
C. Renal failure
D. Cushing’s disease

Answer 148

Cushing’s disease produces elevated cortisol levels. Cortisol is best known for helping support the body’s natural “fight-or-flight” instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance.

Question 149

The nurse reviews laboratory data for a client with suspected diabetes mellitus (DM). Which action should the nurse take based on the client’s hemoglobin A1C of 6.1%?

Answer 149

The hemoglobin A1C value of 6.1% shown is abnormal (normal HgbA1c is below 5.7). Prediabetes is a hemoglobin A1C value from 5.7% to 6.4%. The nurse should educate the client on lifestyle changes such as exercise and consuming foods low in simple carbohydrates. The HgbA1C and fasting blood glucose levels need to be monitored with the goal of both trending downward. If the trend continues, the client risks diabetes mellitus which is diagnosed at a hemoglobin A1C of 6.5% or greater.
✓ Risk factors for type two diabetes include family history, gestational diabetes, being overweight, and being over the age of 45.

✓ Racially, diabetes impacts Asian Americans, African Americans, and Native Americans more than other races.

✓ Diagnosis for type diabetes mellitus includes a hemoglobin A1C of 6.5% or greater. Normal is a level less than 5.7%.

✓ A hemoglobin A1C of 5.7% to 6.4% is concerning for prediabetes.

✓ A fasting plasma blood glucose of 126 mg/dl or more (normal is less than 100 mg/dl) is a provisional diagnosis for DM.

Question 150

Ostomy Stoma Considerations

Answer 150

A stoma should appear beefy red, and moist. This finding indicates adequate perfusion to the stoma. Stomas that are purple, blue, black, and dry are concerned for lack of blood flow.
The appliance should not be changed daily. This will cause the client to run out of supplies, and constantly changing the appliance will increase the risk of skin irritation. The appliance should be changed every 3-5 days.
Moisturizing soap should not be used around the stoma because this decreases adherence to the appliance to the skin. It is recommended that a mild soap be utilized, and the hair around the area be clipped.
It is appropriate that the pouch is emptied when it is one-half to one-third full.
Considering this client is two weeks post-operative, the edema should decrease, and the stoma will reach its normal size within six to eight weeks following surgery.
✓ Teaching a client about ostomy management may be extensive, and it would be appropriate for the nurse to refer the client to a certified wound and ostomy nurse.

✓ Skin care is a significant priority for a client with an ostomy device.

✓ The client should use mild soap, ensure that the peristomal skin is dry before applying the appliance, and clip (not shave) the surrounding hair.

✓ If peristomal skin becomes raw (skin stripping), stoma powder, paste, or a combination may also be applied.

Question 151

clear liquid diet

Answer 151

A clear liquid diet is usually transparent (to light) dietary items that do not contain dairy or pulp.
Items such as water, gelatin, fat-free bouillon, hot tea, apple juice, seltzer, lemonade, and ginger ale are acceptable.
Clear hard candy is acceptable because it is a clear liquid when melted.
Salt and sugar are food additives that are permitted.

A full liquid is the next step when the diet is advanced.
This diet contains opaque liquids.
A full-liquid diet usually contains pulp and dairy.
For example, coffee is a clear liquid, whereas a coffee with creamer or milk is a full liquid.
Items that are full liquid include sherbert, milkshakes, frozen yogurt, pudding, strained soups, and coffee with dairy (or nondairy alternatives such as oat milk).

✓ A clear liquid diet is easily absorbed and digested

✓ This diet often is used for a PO (by mouth) challenge if the client is experiencing nausea and vomiting, if they can tolerate it without further vomiting it is considered a successful challenge

✓ The disadvantage of a clear liquid diet is that it provides very little nutritional value

✓ Salt and sugar additives are permitted

Question 152

Dumping Syndrome

Answer 152

Dumping syndrome is a common complication following gastric bypass surgery. Early dumping syndrome has a rapid onset, usually within 15 minutes. It is the result of rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response. Clients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia. At worst, the client runs the risk of hypoglycemia.