NCLEX Practice Exam for Gastrointestinal Diseases 1

EXPLANATION

✔Correct answer:

Cover the wound with a sterile dressing soaked in saline. In the case of wound evisceration, the immediate priority is to protect the exposed organs and tissue from drying out and becoming contaminated. The most appropriate intervention is to cover the wound and the exposed organs with a sterile dressing soaked in saline. This prevents desiccation of the tissues and reduces the risk of infection until surgical intervention can be performed.

Sterile saline is used to keep the organs moist and protect them from further injury. Applying gentle pressure or attempting to reinsert the organs is contraindicated, as this can cause additional trauma. After covering the wound, the nurse should keep the patient in a low Fowler’s position with the knees slightly flexed to reduce abdominal tension and wait for the surgeon’s arrival.

Imagine you accidentally drop an open box of fragile glass ornaments on the ground. Instead of trying to force the ornaments back into the box (which could break them further), you cover them with a soft, damp cloth to protect them from dust and damage until they can be carefully picked up and stored properly. Similarly, when organs are exposed during wound evisceration, covering them with a moist sterile dressing protects them from contamination and drying until surgery can safely address the issue.

Nurse Clara should focus on stabilizing the patient and preventing further harm until surgical intervention is possible.

• Cover the exposed organs with a moist sterile saline dressing to protect tissues from drying out or becoming contaminated.
• Position the patient in a low Fowler’s position with knees slightly flexed to reduce strain on the abdomen and minimize further protrusion of the organs.
• Reassure the patient and instruct them to avoid coughing, straining, or any movement that may worsen the condition.
• Monitor the patient’s vital signs for signs of shock, such as tachycardia or hypotension, and prepare to provide support as needed.
• Ensure that the patient is NPO (nothing by mouth) in preparation for emergency surgery.
• Notify the physician or surgeon immediately and follow facility protocols for managing wound evisceration.

✘Incorrect answer options:

Gently push the organs back in place and cover with moist sterile dressings: Never attempt to push the organs back into the abdominal cavity, as this can cause further trauma, infection, or injury to the tissues. This is outside the nurse’s scope of practice and should only be done surgically under sterile conditions.

Apply a dry sterile dressing and secure it with a binder: A dry dressing is not appropriate because it will not prevent the exposed organs from drying out. Securing the wound with a binder may increase abdominal pressure, worsening the evisceration.

Irrigate the wound and exposed organs using Betadine solution: Betadine is not recommended for exposed abdominal organs, as it can cause irritation and further damage to the delicate tissues. Only sterile saline should be used to keep the organs moist.

EXPLANATION

✔Correct answer:

Dyspnea. The primary purpose of a paracentesis in a patient with ascites is to remove excess fluid from the peritoneal cavity, alleviating abdominal distension and its associated symptoms, particularly dyspnea (difficulty breathing). Ascites can exert upward pressure on the diaphragm, limiting lung expansion and causing respiratory distress. By removing the accumulated fluid, the diaphragm is able to descend, improving lung capacity and relieving dyspnea.

Monitoring for improvements in breathing is a key indicator of the procedure's success. Other signs of effectiveness may include reduced abdominal girth, less discomfort from abdominal distension, and improved overall comfort.

Imagine trying to inflate a balloon (the lungs) inside a water-filled bucket (the abdomen with ascites). Removing the water makes more room for the balloon to expand, just as draining ascitic fluid relieves pressure on the diaphragm, improving breathing.

After a paracentesis, Nurse Sophia should closely monitor Lewis for signs of improvement as well as potential complications, such as hypovolemia or infection.

• Evaluate for relief of dyspnea and monitor respiratory rate, effort, and oxygen saturation levels to confirm improved breathing.
• Measure abdominal girth pre- and post-procedure to quantify fluid removal and assess for a reduction in distension.
• Monitor blood pressure and heart rate to detect signs of hypovolemia, which can occur due to fluid shifts after large-volume paracentesis.
• Assess for dizziness or orthostatic hypotension, which may indicate vascular volume depletion.
• Monitor for signs of infection, such as fever or abdominal pain, which could occur due to peritoneal contamination during the procedure.

✘Incorrect answer options:

Pruritus: Pruritus (itching) is associated with bile salt accumulation in the skin due to cholestasis in liver disease. Paracentesis does not address bile salt levels or pruritus, so this symptom is unrelated to the effectiveness of the procedure.

Jaundice: Jaundice occurs due to elevated bilirubin levels in liver disease. Paracentesis does not affect bilirubin levels, so it would not relieve jaundice. Jaundice persists regardless of fluid removal from the peritoneal cavity.

Peripheral Neuropathy: Peripheral neuropathy in liver disease is often linked to malnutrition or vitamin deficiencies, such as thiamine or vitamin B12. Paracentesis does not address these underlying causes and would not improve neuropathy.

EXPLANATION

✔Correct answer:

Reassure the client that diarrhea is a normal response. Polyethylene glycol-electrolyte solution (GoLYTELY) is a bowel preparation medication commonly used prior to a colonoscopy. Its primary function is to induce diarrhea to clear the colon of stool, ensuring optimal visualization during the procedure. Diarrhea is an expected and intended effect of this medication, not a complication. Nurse Emma should reassure Ms. Torres that diarrhea is a normal response and indicates that the medication is working as intended.

This reassurance helps alleviate the client's concerns and reinforces the purpose of the preparation process. Nurse Emma should also ensure the client understands the importance of completing the entire dose of the solution as prescribed to achieve adequate bowel cleansing.

Think of GoLYTELY as a detergent for cleaning a window (the colon). The detergent causes water to run down the window (diarrhea), which is exactly what’s needed to leave the surface clear for inspection (the colonoscopy).

While diarrhea is expected, the nurse should monitor for signs of dehydration or other adverse effects related to bowel preparation.

• Encourage the client to drink clear liquids to maintain hydration during the bowel preparation process.
• Educate the client about staying near a restroom, as the medication causes frequent bowel movements.
• Monitor for signs of dehydration, such as dizziness, dry mouth, or reduced urine output, and intervene if necessary.
• Ensure the client has completed the prescribed dose of the solution for effective bowel preparation.
• Answer any questions about the procedure or preparation to reduce client anxiety and increase understanding.

✘Incorrect answer options:

Administer an enema to assist in bowel preparation: An enema is not required when polyethylene glycol-electrolyte solution is used, as the solution itself is sufficient to clear the bowel. Administering an enema would be unnecessary and could cause discomfort.

Initiate an IV infusion for fluid replacement: While hydration is important during bowel preparation, initiating an IV infusion is not routinely necessary unless the client shows significant signs of dehydration, such as hypotension or tachycardia. Most clients can maintain hydration by drinking clear liquids.

Notify the provider to cancel the procedure: Diarrhea is an expected response and does not indicate a need to cancel the colonoscopy. This option would delay the procedure unnecessarily and may result in incomplete preparation.

EXPLANATION

✔Correct answer:

Rebound tenderness in the abdomen. Rebound tenderness in the abdomen is a critical finding that suggests peritoneal irritation, which can be indicative of a serious complication like perforation or peritonitis in a client with ulcerative colitis. Perforation occurs when severe inflammation leads to a tear in the colon, allowing intestinal contents to leak into the peritoneal cavity, which can rapidly progress to life-threatening sepsis. This symptom warrants immediate reporting to the physician for further diagnostic evaluation and intervention, such as imaging studies or surgery, if necessary.

Rebound tenderness refers to pain that worsens when pressure applied to the abdomen is quickly released, a hallmark of peritoneal inflammation. This finding is considered an emergency and requires prompt medical attention.

Think of the colon as a fragile balloon that has been overinflated due to inflammation. If the balloon pops (perforation), its contents spill into the surrounding area, causing irritation and danger. Rebound tenderness is like a warning signal that the "balloon" may have ruptured.

Nurse Clara should immediately inform the physician of the finding and prepare the client for possible diagnostic and emergency interventions.

• Report rebound tenderness and other associated symptoms, such as fever, tachycardia, or abdominal distension, to the physician without delay.
• Monitor the client’s vital signs for signs of shock, including hypotension, tachycardia, or decreased urine output.
• Keep the client NPO (nothing by mouth) in case surgical intervention is needed.
• Prepare the client for potential diagnostic tests, such as abdominal X-rays or CT scans, to evaluate for perforation or peritonitis.
• Administer IV fluids and antibiotics as prescribed to manage infection and maintain hemodynamic stability.

✘Incorrect answer options:

Presence of bloody diarrhea: Bloody diarrhea is a common symptom of ulcerative colitis due to inflammation and ulceration of the colon. While it requires ongoing monitoring, it is not an emergency finding unless accompanied by hemodynamic instability or an alarming increase in severity.

Low blood pressure (hypotension): While hypotension is concerning, it must be assessed in conjunction with other symptoms, such as tachycardia, dizziness, or a significant drop in hemoglobin. If the hypotension is isolated and mild, it does not always require immediate reporting, but it should be closely monitored. Severe hypotension alongside rebound tenderness would indicate shock and demand urgent attention.

A hemoglobin level of 12 mg/dL: A hemoglobin level of 12 mg/dL is within the normal range for females (normal range: 12–15 mg/dL). This does not require immediate reporting unless it is significantly decreasing over time or accompanied by other alarming symptoms, such as severe bleeding or hemodynamic instability.

EXPLANATION

✔Correct answer:

Refrain from coughing to protect the surgical site. After an umbilical hernia repair, it is essential to protect the surgical site to promote healing and prevent complications such as dehiscence (wound reopening) or recurrence of the hernia. Coughing creates intra-abdominal pressure, which can strain the surgical site and increase the risk of damage to the sutures or mesh repair. Nurse James should instruct Mr. Allen to avoid forceful coughing during the recovery period. If coughing is unavoidable (e.g., due to respiratory issues), the client should be advised to splint the surgical area by gently holding a pillow or hand over the site to reduce strain.

The primary goal during recovery is to minimize any actions that could disrupt the surgical repair while encouraging appropriate activity to prevent complications like venous stasis or pneumonia.

Think of the surgical site as a patched hole in a tire. Putting too much pressure on the tire (like forceful coughing) can weaken or disrupt the patch, causing it to fail. Avoiding excessive pressure helps ensure the patch holds securely.

Nurse James should provide clear and comprehensive instructions for post-operative care, focusing on protecting the surgical site and promoting recovery.

• Encourage the client to avoid heavy lifting, straining, or actions that increase intra-abdominal pressure (e.g., sneezing, coughing) for 4–6 weeks.
• Teach the client to splint the surgical site with a pillow if coughing is unavoidable.
• Advise on gradually resuming light activity, such as walking, to promote circulation and prevent complications like deep vein thrombosis (DVT).
• Monitor for signs of infection at the surgical site, such as redness, swelling, drainage, or fever, and report them to the healthcare provider.
• Provide pain management education, including the safe use of prescribed medications and non-pharmacological strategies such as ice packs or relaxation techniques.

✘Incorrect answer options:

Remain on strict bed rest: Strict bed rest is not recommended after an umbilical hernia repair, as it increases the risk of complications such as pneumonia and DVT. Early mobilization, such as walking, is encouraged to promote recovery and circulation.

Perform regular drain irrigations: In most umbilical hernia repairs, drains are not typically required. If a drain is present, it should be managed according to specific healthcare provider instructions, but regular irrigation is not a standard practice.

Limit the use of pain medications: Pain management is an essential part of post-operative care. Clients should be encouraged to use pain medications as prescribed to stay comfortable, which helps promote mobility and recovery. There is no need to arbitrarily limit pain medication use.

EXPLANATION

✔Correct answer:

Lightheadedness accompanied by excessive sweating. Dumping syndrome is a common complication after a Billroth II procedure (gastrojejunostomy), characterized by the rapid emptying of gastric contents into the small intestine. Symptoms of dumping syndrome often occur within 15–30 minutes after eating (early dumping) and are due to a sudden fluid shift into the intestines, triggering autonomic and vasomotor responses.

Key symptoms include:

• Lightheadedness (caused by a drop in blood pressure due to fluid shifts).
• Excessive sweating (a sign of autonomic nervous system activation).
• Nausea, abdominal cramping, diarrhea, tachycardia, and flushing are also common.

These symptoms occur because the rapid influx of hyperosmolar food draws water from the bloodstream into the intestine, leading to vasomotor instability and a decrease in circulating blood volume.

Imagine pouring a large bucket of concentrated liquid into a sponge too quickly—it pulls water from nearby areas and overwhelms the system. Similarly, in dumping syndrome, the sudden movement of food into the intestines causes a dramatic fluid shift, leading to symptoms like sweating and dizziness.

Nurse Amy should educate the patient about dietary modifications and strategies to minimize symptoms of dumping syndrome.

• Encourage the patient to eat small, frequent meals to avoid overloading the stomach and intestines.
• Advise separating food and fluid intake by drinking fluids 30 minutes before or after meals, rather than with meals.
• Recommend avoiding high-sugar foods and beverages, as they exacerbate symptoms by increasing the osmolarity of intestinal contents.
• Suggest reclining or lying down for 20–30 minutes after eating to slow gastric emptying and reduce symptom severity.
• Monitor for signs of late dumping syndrome (1–3 hours after meals), which can cause hypoglycemia due to excessive insulin release following the rapid absorption of glucose.

✘Incorrect answer options:

Headache along with a slow heart rate (bradycardia): Bradycardia and headaches are not typically associated with dumping syndrome. Instead, tachycardia (rapid heart rate) due to autonomic activation is more common.

Flushed appearance with dry skin: While flushing is a symptom of dumping syndrome, dry skin is not. Excessive sweating, not dryness, is a hallmark of this condition due to vasomotor instability.

Difficulty breathing (dyspnea) and chest discomfort: These symptoms are not characteristic of dumping syndrome. Dyspnea and chest discomfort would warrant evaluation for other conditions, such as cardiac or pulmonary complications, rather than dumping syndrome.

EXPLANATION

✔Correct answer:

An elevated serum bilirubin level. An elevated serum bilirubin level is a key indicator of liver dysfunction and is commonly seen in hepatitis. Bilirubin is a byproduct of the breakdown of red blood cells and is normally processed and excreted by the liver. In hepatitis, the liver's ability to metabolize and excrete bilirubin is impaired due to inflammation and hepatocellular damage. This results in an accumulation of bilirubin in the bloodstream, leading to symptoms such as jaundice (yellowing of the skin and eyes), dark urine, and pale stools.

The elevated bilirubin level reflects both the liver’s reduced capacity to conjugate bilirubin (direct bilirubin) and the increased breakdown of red blood cells (indirect bilirubin). Therefore, it serves as a critical diagnostic marker for hepatitis and other liver conditions.

Think of the liver as a factory that processes waste (bilirubin) and sends it out for disposal. If the factory is damaged (hepatitis), the waste starts piling up in the bloodstream (elevated bilirubin), causing noticeable symptoms like jaundice.

When elevated bilirubin is identified, nurses must focus on symptom management, monitoring for complications, and educating the client on proper care.

• Monitor for signs of worsening jaundice, such as intensifying yellowing of the skin or sclera and itching (pruritus).
• Encourage a low-fat diet to reduce the strain on the liver and prevent steatorrhea (fatty stools).
• Educate the client to avoid alcohol and hepatotoxic medications to prevent further liver damage.
• Monitor liver function tests (e.g., ALT, AST, ALP) alongside bilirubin levels to assess liver inflammation and recovery.
• Reinforce the importance of adequate hydration and rest to support liver function and recovery.

✘Incorrect answer options:

An elevated blood urea nitrogen (BUN) level: BUN measures kidney function and is not directly indicative of liver dysfunction or hepatitis. Elevated BUN levels are typically associated with kidney conditions, dehydration, or high protein intake, not hepatitis.

A decreased erythrocyte sedimentation rate (ESR): ESR is a nonspecific marker of inflammation and is not directly linked to liver function. In hepatitis, ESR levels might increase due to inflammation, but a decreased ESR is not characteristic of hepatitis.

An elevated hemoglobin level: Elevated hemoglobin levels are not associated with hepatitis. They are more often related to conditions such as polycythemia or chronic hypoxia. Hepatitis does not typically affect hemoglobin levels directly.

EXPLANATION

✔Correct answer:

Record the drainage findings in the client’s chart. It is normal for a T-tube to drain 500–1,000 mL of green-brown bile in the first 24 hours post-cholecystectomy. The purpose of the T-tube is to facilitate bile drainage from the common bile duct while swelling decreases and normal bile flow is restored. Since the drainage amount (750 mL) and color (green-brown bile) are within expected limits, the most appropriate action for Nurse Daniel is to document the findings in the client’s chart and continue to monitor the drainage output over time.

Recording the drainage output provides an accurate record of the client’s condition, which helps monitor trends, identify potential complications, and ensure the T-tube is functioning properly. Nurse Daniel should continue to assess the drainage for changes in color, amount, or consistency that might indicate a complication.

Think of the T-tube as a temporary drainage pipe used to divert bile while the body adjusts after surgery. Just like a construction worker monitors how much water flows through a pipe, Nurse Daniel keeps track of the bile drainage to ensure the system is functioning correctly.

Nurse Daniel should remain vigilant in monitoring and managing the T-tube to ensure proper post-operative recovery and to detect complications early.

• Continue to monitor the amount, color, and consistency of the T-tube drainage, and record findings regularly.
• Notify the physician if the drainage amount exceeds 1,000 mL in 24 hours, if the drainage suddenly stops, or if the drainage changes to a concerning color (e.g., bloody, purulent).
• Ensure the T-tube remains secured to prevent accidental dislodgement and that there are no kinks or blockages in the tubing.
• Educate the client about the purpose of the T-tube and the expected drainage process to alleviate anxiety.
• Assess for signs of infection around the insertion site, such as redness, swelling, or discharge.

✘Incorrect answer options:

Irrigate the T-tube to maintain patency: Irrigation is not routinely performed unless specifically ordered by the physician, as improper irrigation could damage the bile duct or cause bile leakage.

Notify the physician immediately about the output: Since 750 mL of green-brown fluid within the first 24 hours is expected, there is no need to notify the physician at this time. However, the physician should be informed if the output exceeds 1,000 mL or if other abnormalities are observed.

Clamp the T-tube to limit further drainage: Clamping the T-tube is not appropriate unless ordered by the physician as part of a trial to assess the bile duct's patency before removing the tube. Unilaterally clamping the tube could lead to bile accumulation and complications.

EXPLANATION

✔Correct answer:

Clamp the nasogastric tube for 30 minutes after giving the medication. Clamping the nasogastric (NG) tube for 30 minutes after medication administration allows the medication to remain in the stomach or small intestine for absorption, rather than being immediately suctioned out. Medications given via an NG tube typically require time to be absorbed into the bloodstream. If the NG tube is connected to continuous or intermittent suction, failing to clamp it after medication administration may lead to the medication being removed before it has a chance to take effect, rendering the administration ineffective.

Key Clinical Considerations:

1. Medication Absorption: Most medications need time in the gastrointestinal (GI) tract to dissolve and be absorbed. The stomach’s acidic environment often plays a role in activating or breaking down medications.
2. Clamping Best Practice: Temporarily stopping suction by clamping the NG tube prevents medication loss while ensuring the patient's safety and therapeutic outcomes. After the 30-minute period, suction can be resumed as needed to manage gastric secretions or decompression.

Imagine pouring water on a sponge to let it soak in. If you immediately squeeze the sponge, the water will be removed before it can be absorbed. Similarly, clamping the NG tube gives the "sponge" (GI tract) time to absorb the medication before suction removes it.

Proper medication administration via an NG tube involves these steps to ensure safety and effectiveness:

• Verify tube placement before administering medication, typically by checking gastric residual volume and confirming via pH testing or other facility protocols.
• Flush the NG tube with 15-30 mL of water before and after administering each medication to maintain tube patency and prevent clogging.
• Administer liquid forms of medication when available or crush pills (if permitted) and dilute them with water for easier administration.
• Clamp the tube or pause suction for 30 minutes to ensure medication absorption before resuming suction as prescribed.
• Document the administration, including the time the tube was clamped and suction resumed, to ensure proper care continuity.

✘Incorrect answer options:

Adjust the suction to low intermittent for 30 minutes post-administration. Reducing suction intensity does not prevent the medication from being removed. Suction should be completely stopped by clamping the NG tube to allow proper absorption.

Place the client in a supine position to enhance medication absorption. A supine position increases the risk of aspiration, especially in clients with NG tubes. Instead, the patient should be kept in a semi-Fowler’s or high-Fowler’s position (30-45 degrees) to reduce this risk and promote proper medication absorption.

Aspirate the nasogastric tube following medication administration to keep it open. Aspirating the NG tube immediately after administering medications would remove the medication along with any gastric contents, making the administration ineffective. Flushing with water, not aspiration, should be performed to maintain tube patency.

EXPLANATION

✔Correct answer:

Isosorbide dinitrate (Isordil). Achalasia is a condition characterized by the failure of the lower esophageal sphincter (LES) to relax properly and ineffective esophageal motility, leading to symptoms such as dysphagia, regurgitation, and chest discomfort. Isosorbide dinitrate (Isordil), a nitrate, helps manage achalasia by relaxing smooth muscle, including the lower esophageal sphincter. Nitrates reduce the pressure in the LES, facilitating the passage of food and liquids from the esophagus into the stomach.

Isosorbide dinitrate achieves this effect by releasing nitric oxide, which activates smooth muscle relaxation pathways. This pharmacologic approach provides symptomatic relief for patients who experience significant difficulty swallowing due to a hypertonic LES.

Think of the LES as a tight gate that won't open easily. Isosorbide dinitrate works like oil applied to the gate hinges, making it easier to relax and open for food to pass through.

Nurse Daniel should monitor the patient’s response to therapy and provide additional education and interventions to manage achalasia symptoms effectively.

• Administer isosorbide dinitrate as prescribed, typically before meals, to maximize its effect on esophageal motility during swallowing.
• Monitor the patient for potential side effects of nitrates, such as headache, dizziness, hypotension, or flushing, and educate the patient about these possible effects.
• Advise the patient to eat slowly, chew food thoroughly, and consume small, frequent meals to reduce esophageal discomfort.
• Position the patient upright during and after meals to minimize regurgitation and improve gravity-assisted esophageal emptying.
• Collaborate with the healthcare provider to assess the need for other treatments, such as calcium channel blockers, pneumatic dilation, or surgical interventions like Heller myotomy if symptoms persist.

✘Incorrect answer options:

Captopril (Capoten): Captopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not relax the smooth muscle of the lower esophageal sphincter or improve symptoms of achalasia.

Digoxin (Lanoxin): Digoxin is a cardiac glycoside used to treat heart failure and atrial fibrillation. It has no role in relaxing the esophageal sphincter or enhancing esophageal motility in achalasia.

Propranolol (Inderal): Propranolol is a beta-blocker used to manage hypertension, anxiety, and arrhythmias. Beta-blockers can worsen achalasia by increasing smooth muscle tone and potentially raising LES pressure.

EXPLANATION

✔Correct answer:

Advise avoiding fluids during mealtime. Dumping syndrome, a common complication after a Billroth II procedure (gastrojejunostomy), occurs when food moves too quickly from the stomach to the small intestine. This can result in symptoms such as nausea, diarrhea, abdominal cramping, dizziness, and sweating. Avoiding fluids during mealtime is essential to manage dumping syndrome because drinking fluids with meals accelerates gastric emptying and contributes to the rapid shift of food and liquids into the small intestine, worsening symptoms.

Instead, patients should be encouraged to drink fluids 30 minutes before or 30–60 minutes after meals to slow gastric emptying and prevent the osmotic shifts that lead to dumping syndrome. Separating food and fluid intake allows the stomach to process solids more gradually and reduces the risk of symptoms.

Imagine pouring food and water down a funnel at the same time—the flow is too fast, and the funnel gets overwhelmed. By separating the two, the system works more efficiently and avoids overload, just like the digestive system after a Billroth II procedure.

Nurse Kelly should educate Mr. Lopez on dietary adjustments to manage dumping syndrome effectively.

• Encourage the client to eat small, frequent meals (5–6 per day) to prevent overloading the stomach and reduce symptoms.
• Instruct the client to avoid drinking fluids during meals and wait at least 30 minutes after eating before consuming liquids.
• Recommend a diet high in protein and moderate in fat, as these nutrients slow gastric emptying and are less likely to trigger dumping syndrome.
• Advise limiting simple carbohydrates (e.g., sugary foods and drinks), which increase the osmotic pull in the small intestine and exacerbate symptoms.
• Encourage the client to lie down or recline for 20–30 minutes after meals to slow gastric emptying and minimize symptoms.

✘Incorrect answer options:

Encourage increasing carbohydrate-rich foods: Carbohydrates, especially simple sugars, are the primary culprits in triggering dumping syndrome. They increase osmotic pressure in the intestine, leading to fluid shifts, diarrhea, and cramping. Patients should limit carbohydrate intake, particularly simple sugars, to reduce symptoms.

Suggest reducing dietary fat consumption: Reducing dietary fat is not recommended for dumping syndrome. Fat slows gastric emptying, which can be beneficial in managing symptoms. A moderate-fat diet is usually advised to help delay food movement into the small intestine.

Recommend cutting back on protein intake: Protein is crucial for managing dumping syndrome because it slows gastric emptying and provides essential nutrients for healing and energy. Cutting back on protein would worsen symptoms and negatively impact recovery.

EXPLANATION

✔Correct answer:

Frequent diarrhea. In clients with Crohn’s disease, frequent diarrhea is a hallmark symptom due to the chronic inflammation of the gastrointestinal (GI) tract. This inflammation disrupts normal absorption and digestion, leading to loose stools. Crohn's disease can affect any part of the GI tract from the mouth to the anus, but the most commonly affected areas are the terminal ileum and the colon. When the small intestine is involved, it impairs absorption of nutrients and bile salts, contributing to watery diarrhea. Additionally, inflammation of the colon further exacerbates diarrhea due to irritation and reduced water absorption.

Clients with Crohn's disease may also experience abdominal cramping, urgency, and fatigue due to the frequent loss of fluids and electrolytes through diarrhea. Managing these symptoms is a key component of nursing care.

Think of the inflamed intestine like a water hose with holes. Instead of allowing water (nutrients and fluids) to flow smoothly, the leaks (inflammation) cause water to spill out prematurely, leading to frequent watery stools.

Nurse Elena should focus on managing diarrhea, maintaining hydration, and educating Ms. Roberts about symptom management.

• Monitor stool frequency, consistency, and volume to assess disease activity and hydration status.
• Encourage the client to drink fluids with electrolytes to replace losses from frequent diarrhea.
• Collaborate with a dietitian to develop a low-residue diet plan, which may help reduce stool frequency during flare-ups.
• Administer prescribed medications, such as antidiarrheals, anti-inflammatory agents, or immunosuppressants, to manage symptoms and reduce inflammation.
• Educate the client to recognize signs of complications, such as blood in the stool or severe dehydration, and to report them immediately.

✘Incorrect answer options:

Alternating episodes of constipation and diarrhea: Alternating constipation and diarrhea is more characteristic of irritable bowel syndrome (IBS), not Crohn’s disease. Crohn’s disease is primarily associated with persistent diarrhea during flare-ups.

Continuous oozing of stool from the rectum: This finding is more indicative of fecal incontinence or a fistula associated with severe rectal disease. While fistulas can occur in Crohn’s disease, continuous oozing of stool is not a hallmark symptom.

Persistent constipation: Persistent constipation is not a common feature of Crohn’s disease. Instead, constipation is more often seen in conditions like diverticulitis or intestinal obstruction. Crohn’s disease is characterized by diarrhea rather than constipation.

EXPLANATION

✔Correct answer:

1.030. A urine specific gravity of 1.030 is indicative of dehydration. Persistent diarrhea, as seen in patients with Crohn's disease, leads to significant fluid loss, which concentrates the urine and increases its specific gravity. Specific gravity is a measure of the concentration of solutes in urine and reflects the kidney's ability to conserve water. Normal urine specific gravity typically ranges from 1.005 to 1.030, with higher values (closer to 1.030) indicating concentrated urine due to dehydration or fluid loss.

In this scenario, the patient has had 4 days of persistent diarrhea, leading to decreased fluid volume and increased urine concentration. Nurse Carla should recognize that a specific gravity of 1.030 strongly suggests dehydration and take prompt measures to rehydrate the patient.

Think of urine as a glass of lemonade. If water is lost (like during dehydration), the remaining lemonade becomes more concentrated and sweeter, just as urine becomes more concentrated with a higher specific gravity during dehydration.

Nurse Carla should focus on correcting dehydration and monitoring the patient for further complications.

• Administer oral or IV fluids as prescribed to restore hydration and electrolyte balance, particularly if the patient is unable to tolerate oral intake.
• Monitor the patient’s vital signs for signs of dehydration, such as tachycardia, hypotension, or orthostatic changes.
• Encourage the patient to drink electrolyte-containing fluids, such as oral rehydration solutions, to replace losses from diarrhea.
• Assess the patient’s electrolyte levels (e.g., sodium, potassium) and kidney function, as persistent diarrhea can lead to imbalances and organ stress.
• Document and monitor urine output to evaluate hydration status and response to treatment.
• Provide education about managing diarrhea and preventing dehydration, including dietary modifications and when to seek medical care.

✘Incorrect answer options:

1.005: A specific gravity of 1.005 suggests dilute urine, which is not expected in a dehydrated patient. This value is more common in conditions of overhydration, diabetes insipidus, or kidney inability to concentrate urine.

1.011: A specific gravity of 1.011 falls within the normal range but does not indicate significant concentration of the urine. This value is less likely in the context of persistent diarrhea and dehydration.

1.020: While a specific gravity of 1.020 is mildly concentrated and could indicate mild dehydration, it is not as indicative of severe dehydration as 1.030. Given the patient’s 4 days of diarrhea, 1.030 is more likely.

EXPLANATION

✔Correct answer:

Take a deep breath and hold it. During nasogastric (NG) tube removal, asking the client to take a deep breath and hold it momentarily helps close the glottis (via the epiglottis), which minimizes the risk of aspiration. When the glottis is closed, it prevents any gastric contents or secretions from being inhaled into the respiratory tract while the tube is withdrawn. This technique also reduces patient discomfort and facilitates a smooth removal process.

Key Considerations During NG Tube Removal:

1. Preventing Aspiration: Closing the glottis by holding the breath creates a protective barrier against gastric secretions or reflux being drawn into the trachea.
2. Reducing Discomfort: A controlled, swift withdrawal while the patient holds their breath minimizes irritation to the throat and nasal passages.
3. Patient Safety: Ensuring proper preparation and technique reduces complications and enhances patient comfort.

Think of the airway like a gate that can be closed to protect a garden from unwanted intrusions. Asking the patient to take a deep breath and hold it temporarily "closes the gate" (the glottis), preventing anything from accidentally entering the airway while the NG tube is being removed. This simple action ensures that the airway stays protected, just like a closed gate keeps the garden safe while you work.

When removing an NG tube, ensure patient safety and comfort by following these steps:

• Inform the patient about the procedure and what to expect to reduce anxiety and promote cooperation.
• Position the patient in a semi-Fowler’s or high-Fowler’s position to reduce the risk of aspiration.
• Ask the patient to take a deep breath and hold it just before removing the tube.
• Remove the tube quickly but gently in one smooth motion to minimize discomfort.
• Inspect the tube for intactness after removal and document the procedure, including the patient’s tolerance and any unusual findings.
• Monitor the patient for any signs of respiratory distress or complications after the procedure.

✘Incorrect answer options:

Perform a Valsalva maneuver. The Valsalva maneuver involves forceful exhalation against a closed airway and is typically used to prevent air embolism during central line removal, not NG tube removal. It is unnecessary and inappropriate in this context.

Breathe in and out rapidly. Rapid breathing can cause hyperventilation and unnecessary anxiety. Additionally, it does not provide the protective closure of the airway needed during NG tube removal.

Breathe out gently. Exhaling gently during tube removal would leave the airway open and increase the risk of aspiration if gastric contents are present near the tube or upper esophagus.

EXPLANATION

✔Correct answer:

Start with observation, then auscultation, followed by percussion, and finish with palpation. The correct sequence for an abdominal assessment is observation (inspection), auscultation, percussion, and palpation. This sequence is used to ensure that the assessment does not interfere with normal bowel sounds, which can be disrupted by percussion or palpation.

• Observation (Inspection): The first step is to visually assess the abdomen for signs of distension, discoloration, visible masses, scars, or asymmetry. This step is non-invasive and provides critical baseline information.
• Auscultation: After inspection, auscultation is performed to listen to bowel sounds before any manipulation of the abdomen, as percussion and palpation can alter these sounds. The nurse listens to all four quadrants for the presence, absence, or abnormality of bowel sounds.
• Percussion: Percussion follows auscultation and is used to assess the underlying structures, identify fluid or gas, and detect organ size and density.
• Palpation: The final step is palpation, which involves using the hands to feel for masses, tenderness, or organ enlargement. Palpation is performed last to avoid stimulating peristalsis, which could interfere with the accuracy of auscultation or percussion findings.

This sequence minimizes the risk of altering normal bowel activity during the assessment and ensures accurate results.

Imagine assessing the performance of a calm river. First, you observe its surface (inspection), listen to its flow (auscultation), tap on its rocks to understand depth (percussion), and finally touch the water to feel its temperature (palpation). Disrupting it too early (e.g., touching first) would change its natural state and affect your findings.

Nurse Taylor should follow this sequence while being mindful of the client’s comfort and specific symptoms.

• Observe for signs of discomfort or pain during inspection, auscultation, percussion, and palpation, and note the client’s verbal and nonverbal responses.
• Use a warm stethoscope to avoid causing discomfort during auscultation.
• Avoid deep or forceful palpation in areas of known tenderness to prevent unnecessary pain or injury.
• Document findings from each step systematically, noting any abnormal bowel sounds, tenderness, masses, or distension.
• Educate the client about the procedure and its purpose to reduce anxiety and promote cooperation.

✘Incorrect answer options:

Begin with palpation, followed by percussion, observation, and auscultation: Palpation should never be performed first as it can stimulate peristalsis or cause pain, altering bowel sounds and leading to inaccurate findings.

Conduct observation first, proceed to percussion, then palpation, and end with auscultation: While inspection is appropriately performed first, percussion and palpation can alter bowel sounds, so auscultation should always follow inspection.

Perform percussion first, move to palpation, then auscultation, and lastly observation: This sequence disrupts the natural order of assessment. Observation should always be the first step, and auscultation must follow before percussion or palpation to ensure accurate findings.

EXPLANATION

✔Correct answer:

Observation of asterixis. Asterixis, also known as the "liver flap," is a hallmark sign of hepatic encephalopathy, a serious complication of liver cirrhosis. It is characterized by a flapping tremor of the hands that occurs when the patient extends their arms and dorsiflexes their wrists. Asterixis is caused by the accumulation of neurotoxins, such as ammonia, in the bloodstream due to the liver's inability to detoxify them effectively. These toxins impair brain function, leading to the neurologic symptoms of hepatic encephalopathy.

Other signs of hepatic encephalopathy include confusion, altered level of consciousness, lethargy, slurred speech, and, in severe cases, coma. Identifying asterixis is crucial for diagnosing hepatic encephalopathy and initiating prompt treatment, such as lactulose or rifaximin, to reduce ammonia levels.

Think of the brain as a computer that relies on clean energy (filtered blood). When the liver fails, toxins accumulate like "dirty fuel," causing the computer to malfunction, leading to symptoms like the hand flapping seen in asterixis.

Nurse Elena should closely monitor for signs of hepatic encephalopathy and take steps to prevent further progression.

• Assess for asterixis by having the patient extend their arms with their wrists dorsiflexed. Observe for the characteristic flapping motion.
• Monitor the patient’s mental status for signs of confusion, drowsiness, or irritability, which may indicate worsening encephalopathy.
• Administer prescribed medications, such as lactulose (to promote ammonia excretion through the stool) or rifaximin (to reduce ammonia-producing gut bacteria).
• Educate the patient and family about dietary restrictions, including limiting dietary protein if recommended, to reduce ammonia production.
• Monitor laboratory results, particularly serum ammonia levels, liver function tests, and electrolyte levels, to guide treatment.
• Ensure patient safety by preventing falls or injuries due to confusion or altered mental status.

✘Incorrect answer options:

Positive hepatojugular reflux: Hepatojugular reflux is an indication of right-sided heart failure or fluid overload. While liver congestion may occur in cirrhosis due to portal hypertension, this finding is not indicative of hepatic encephalopathy.

Presence of Trousseau’s sign: Trousseau’s sign is associated with hypocalcemia and is characterized by carpal spasms when blood flow to the hand is occluded (e.g., with a blood pressure cuff). It is unrelated to hepatic encephalopathy or liver cirrhosis.

Presence of Chvostek’s sign: Chvostek’s sign is also associated with hypocalcemia and is elicited by tapping the facial nerve, causing facial twitching. This sign is not related to hepatic encephalopathy or liver cirrhosis.

EXPLANATION

✔Correct answer:

Custard. A full liquid diet consists of foods and beverages that are liquid or turn into liquid at body temperature and provide more nutritional value compared to a clear liquid diet. Custard is appropriate because it is smooth, creamy, and melts into liquid form when consumed, making it suitable for the full liquid diet. Full liquid diets are designed to provide more calories and nutrients than a clear liquid diet while still being easy to digest, making them a common step in diet progression for post-operative clients or those with swallowing difficulties.

Custard is also a good source of protein and carbohydrates, which are essential for tissue repair and energy post-surgery. Its consistency is manageable for clients transitioning to more substantial foods.

Think of a full liquid diet as a "bridge" between water and solid food. If clear liquids (like tea or gelatin) are like walking on a thin plank, full liquids (like custard) give more stability, like walking on a wider plank, providing more nutrition while still being easy to handle.

Nurses should ensure that clients transitioning to a full liquid diet can tolerate the new foods without nausea, vomiting, or abdominal discomfort.

• Monitor for signs of intolerance to the full liquid diet, such as bloating, cramping, or nausea.
• Encourage small, frequent meals to help the client adjust to the new diet stage gradually.
• Ensure foods offered meet nutritional needs, including protein, to support healing and recovery.
• Educate the client on the purpose of the full liquid diet and the importance of advancing slowly to avoid complications.
• Collaborate with a dietitian to create a diet plan tailored to the client's needs and preferences.

✘Incorrect answer options:

Gelatin: While gelatin is part of a clear liquid diet, it is not considered a full liquid. Clear liquids like gelatin are low in nutrients and are used in the earlier stages of diet progression before transitioning to full liquids.

Popsicle: Popsicles are also part of a clear liquid diet because they melt into a thin liquid and do not provide significant nutritional value. They are appropriate for hydration but do not meet the caloric or protein needs of a full liquid diet.

Tea: Tea is a clear liquid and is not part of the full liquid diet. Although it can help with hydration, it does not provide the additional calories or nutrients needed for recovery in the full liquid stage.

EXPLANATION

✔Correct answer:

Empty her bladder completely. Before a paracentesis, it is essential for the patient to empty their bladder completely to minimize the risk of accidental injury during the procedure. A paracentesis involves inserting a needle or catheter into the peritoneal cavity to remove excess fluid (ascites), and a distended bladder could be at risk of puncture due to its proximity to the needle insertion site. Ensuring the bladder is empty improves the safety of the procedure and prevents complications such as bladder perforation.

This instruction is a standard pre-procedure guideline and is critical for ensuring the patient's safety and comfort during the procedure.

Think of the abdomen as a crowded room. Removing large objects (like a full bladder) clears space, reducing the risk of bumping into them when someone moves through the room (during needle insertion).

Nurse Grace should ensure that the patient understands all pre-procedure instructions and is adequately prepared for the paracentesis.

• Instruct the patient to void immediately before the procedure to prevent bladder injury.
• Position the patient in a semi-Fowler’s or upright position during the procedure to allow fluid to collect in the lower abdomen, facilitating easier drainage.
• Explain the purpose and process of the paracentesis to alleviate any fears or anxiety about the procedure.
• Monitor the patient’s vital signs before and after the procedure to detect any signs of hypovolemia or hemodynamic instability due to fluid shifts.
• Ensure the patient has intravenous access available, if needed, to administer albumin or fluids to prevent complications related to fluid removal.

✘Incorrect answer options:

Lie flat on her back in bed: Lying flat is not recommended for paracentesis. Patients are typically positioned in a semi-Fowler’s or upright position to allow fluid to pool in the lower abdomen, making it easier to access and drain.

Avoid eating or drinking for 4 hours: While fasting may be required for certain invasive procedures, it is not necessary for a paracentesis. The procedure does not involve sedation or direct interference with the digestive system.

Use an enema to clean her bowels: Bowel cleansing is not required for paracentesis. The focus is on ensuring the bladder is empty to prevent injury during needle insertion, rather than addressing the bowel.

EXPLANATION

✔Correct answer:

Avoid eating or drinking for 8 hours prior to the test. A barium swallow is a diagnostic procedure used to evaluate the esophagus, stomach, and upper gastrointestinal (GI) tract. To ensure accurate imaging results, the client must avoid eating or drinking for 8 hours prior to the test. Fasting prevents food, fluids, or gastric secretions from interfering with the visualization of the GI tract during the x-ray. By adhering to this instruction, the barium can coat the lining of the esophagus and stomach effectively, allowing clear and detailed imaging.

The fasting period minimizes the risk of aspiration and ensures that the GI tract is free of residual food or liquid that could obscure abnormalities or create diagnostic errors.

Think of preparing for the barium swallow like taking a photo of a clean table. If the table is covered with crumbs (food in the GI tract), it’s hard to see its surface clearly. Fasting ensures the "table" is clean, so the barium can reveal the structure without obstructions.

Nurse Anna should provide clear instructions to Ms. Lopez to prepare for the barium swallow effectively and ensure Ms. Lopez understands the steps required for the test.

• Reinforce the importance of fasting for at least 8 hours prior to the procedure to prevent interference with imaging.
• Educate the client to expect possible constipation after the procedure due to the barium. Encourage fluid intake and, if necessary, the use of a mild laxative to prevent complications.
• Inform the client that stools may appear white or chalky for 24–72 hours after the procedure, which is normal as the barium is excreted.
• Ensure the client understands the procedure and has the opportunity to ask questions about the process.
• Verify that the client does not have a history of barium allergy or contraindications to the test.

✘Incorrect answer options:

Keep track of your bowel movements to check for constipation: While monitoring for constipation is important after the procedure, this is not a pre-procedure instruction. This advice is relevant for post-procedure care, as barium can harden and cause constipation if not adequately excreted.

Take all your oral medications as usual: Clients are typically instructed to avoid all oral intake, including medications, for 8 hours before the procedure unless otherwise specified by the physician. Medications that require food or liquids for administration should be discussed with the healthcare provider.

Have a regular dinner and breakfast before the procedure: Eating a regular dinner or breakfast is contraindicated before a barium swallow, as any food in the GI tract can interfere with the test results. The client must remain NPO (nothing by mouth) for at least 8 hours prior to the procedure.

EXPLANATION

✔Correct answer:

Formed. The stool from a sigmoid colostomy is typically formed because the sigmoid colon is the final portion of the large intestine, where water absorption is nearly complete. By the time the stool reaches this part of the colon, it has been processed into a solid, well-formed consistency, similar to normal bowel movements before surgery. This consistency reflects the colon's ability to absorb water and electrolytes, and it aligns with the normal functioning of the distal bowel.

Clients with a sigmoid colostomy are more likely to have predictable bowel movements, which can often be managed through dietary adjustments or colostomy irrigation.

Think of the large intestine like a sponge that absorbs water from the stool as it moves along. By the time it reaches the sigmoid colon, most of the water has been absorbed, leaving the stool solid and formed.

Nurse Megan should educate Mr. Harris about what to expect regarding stool consistency and how to manage his sigmoid colostomy effectively.

• Teach the client how to maintain skin integrity around the stoma by using appropriate barriers and cleaning techniques, as formed stool can irritate the skin if leakage occurs.
• Encourage a balanced diet rich in fiber (as tolerated) to promote regular bowel movements and prevent constipation.
• Educate the client about staying hydrated to ensure adequate water balance, even though stool is formed.
• Discuss the possibility of colostomy irrigation to regulate bowel movements, giving the client more control over their colostomy output.
• Provide emotional support and resources, such as ostomy support groups, to help the client adjust to life with a colostomy.

✘Incorrect answer options:

Semisolid: Semisolid stool is more typical of a colostomy located in the descending colon, where stool is still somewhat formed but not as fully processed as in the sigmoid colon. This is not the expected stool consistency for a sigmoid colostomy.

Semiliquid: Semiliquid stool is characteristic of colostomies located in the transverse colon, where water absorption is less complete compared to the descending or sigmoid colon.

Watery: Watery stool is typically seen in ileostomies, where the stoma is located in the small intestine. In this case, water absorption is minimal, resulting in liquid stool. It is not expected with a sigmoid colostomy.

EXPLANATION

✔Correct answer:

Immediately withdraw the tube and provide oxygen support if needed. Coughing and difficulty breathing during nasogastric (NG) tube insertion are signs that the tube may have entered the airway instead of the esophagus. This situation poses a risk of airway obstruction, aspiration, or trauma to the respiratory tract. Nurse Amy should immediately withdraw the tube to prevent further complications, such as damage to the trachea or aspiration pneumonia. Oxygen support may be needed to address any respiratory distress caused by this event.

NG tube insertion requires constant monitoring for signs of respiratory compromise. Ensuring patient safety takes priority over completing the procedure. Proper technique and immediate response to adverse signs help minimize risks.

Imagine threading a wire into a pipe. If the wire goes into the wrong opening and blocks air or liquid flow, you immediately remove it to prevent damage or further problems. Similarly, withdrawing the NG tube promptly prevents harm when it enters the wrong pathway (the airway).

The priority is the patient's safety during and after the procedure. These steps should be followed:

• Immediately stop advancing the tube and withdraw it if the patient exhibits signs of airway compromise, such as coughing, choking, or difficulty breathing.
• Reassess the patient’s respiratory status and provide oxygen support if needed to alleviate respiratory distress.
• Monitor the patient for additional signs of aspiration or complications, such as abnormal breath sounds, cyanosis, or persistent coughing.
• Reinforce proper technique when reinserting the NG tube, including head positioning (e.g., chin-tuck position) to guide the tube into the esophagus and avoid the airway.
• Ensure verification of tube placement using methods such as pH testing of aspirate or X-ray confirmation before initiating any feedings or medication administration.

✘Incorrect answer options:

Continue advancing the tube slowly while reassuring the patient. This action is unsafe. Advancing the tube despite signs of airway compromise could worsen the situation, potentially leading to airway injury, aspiration, or complete obstruction.

Pause the procedure, instruct the patient to take deep breaths, and resume once he calms down. While calming the patient is important, resuming the procedure without withdrawing the tube would be inappropriate in this case. The tube must be removed immediately if it enters the airway to prevent further complications.

Remove the tube completely and prepare to reinsert it after assessing the situation. While this may seem like a reasonable approach, it does not address the immediate need to stop the airway compromise. The correct response prioritizes withdrawing the tube immediately and addressing the patient’s respiratory distress before planning reinsertion.

EXPLANATION

✔Correct answer:

Red and moist. A healthy and normal stoma should appear red and moist, resembling the inside of the mouth. This indicates adequate blood supply to the stoma, which is critical for healing and proper function. The stoma is created from the intestinal mucosa, so its appearance reflects its vascularity and overall health. A red, moist stoma with no signs of discoloration, dryness, or necrosis suggests that the stoma is functioning as expected and is well-healed.

The nurse should also monitor for other signs of a healthy stoma, such as the absence of swelling, bleeding, or discharge, and ensure that the surrounding skin is intact and free of irritation or breakdown.

Think of the stoma as a fresh, healthy strawberry. Its red, moist appearance shows it's alive and well-nourished, just like a healthy stoma receiving adequate blood supply.

Nurse Carla should provide ongoing care and education to ensure the client maintains a healthy stoma and surrounding skin.

• Assess the stoma daily for color, moisture, size, and any signs of complications, such as discoloration or excessive bleeding.
• Educate the client on how to clean and care for the stoma properly, using warm water and mild soap if necessary.
• Monitor the skin around the stoma for irritation or breakdown due to leakage, and recommend the use of appropriate skin barriers or appliances to protect the peristomal area.
• Reinforce the importance of staying hydrated and consuming a balanced diet to maintain regular ostomy output and overall health.
• Provide emotional support and refer the client to an ostomy support group if needed, as adjusting to a colostomy can be challenging for many individuals.

✘Incorrect answer options:

Pale, pink, and moist: While moisture is important, a pale or pink stoma indicates insufficient blood supply (ischemia) and is abnormal. This finding requires immediate evaluation to ensure that circulation to the stoma is not compromised.

Dark or purple in color: A dark or purple stoma indicates poor blood flow or venous congestion, which is a serious concern that could signal necrosis. This requires immediate intervention by the healthcare team.

Dry and black: A dry and black stoma indicates necrosis (tissue death), which is a medical emergency. This condition can occur due to a lack of blood supply and must be reported immediately for evaluation and possible surgical intervention.

EXPLANATION

✔Correct answer:

Yogurt. Yogurt is a recommended food for clients with a colostomy experiencing excessive flatus because it contains probiotics, which help promote a healthy balance of gut bacteria. Probiotics can aid in digestion and reduce the production of gas in the intestines. In addition, yogurt is generally well-tolerated and less likely to produce gas compared to other foods. Including yogurt in the diet can help minimize flatus and reduce discomfort associated with excessive gas.

Probiotics in yogurt, such as Lactobacillus and Bifidobacterium species, can improve gut health by decreasing the fermentation of certain undigested carbohydrates, which is a major source of intestinal gas.

Think of yogurt as a "peacekeeper" for the gut, helping to balance out the bacteria that produce gas, much like a referee controlling a noisy crowd, making things calmer and more manageable.

Nurse Jamie should educate the client about foods that may increase or decrease gas production and provide strategies to manage excessive flatus.

• Recommend foods that contain probiotics, such as yogurt or fermented products, to help balance gut bacteria and reduce gas production.
• Educate the client to avoid gas-producing foods, such as beans, broccoli, cabbage, carbonated beverages, and peas, as they can increase intestinal gas.
• Encourage the client to eat smaller, more frequent meals and chew food slowly to minimize swallowed air, which can contribute to flatus.
• Suggest avoiding drinking through straws and chewing gum, as these activities can also increase swallowed air and lead to gas buildup.
• Monitor for other symptoms, such as abdominal pain or bloating, which may indicate underlying issues requiring further evaluation.

✘Incorrect answer options:

Broccoli: Broccoli is a gas-producing food because it contains raffinose, a complex carbohydrate that is fermented by gut bacteria, leading to increased gas. This food should be avoided by clients experiencing excessive flatus.

Cabbage: Cabbage is another common gas-producing food that contains raffinose and sulfur compounds, which can increase flatus. It is not recommended for managing excessive gas.

Peas: Peas are legumes that are high in fiber and raffinose, making them likely to cause gas production. They should be limited if the client is experiencing excessive flatus.

EXPLANATION

✔Correct answer:

Pork. Pork is one of the richest dietary sources of thiamine (vitamin B1), which is crucial for clients with cirrhosis, particularly those with a history of alcohol abuse. Thiamine plays a critical role in energy metabolism and the functioning of the nervous system. Chronic alcohol abuse, a common cause of cirrhosis, often leads to thiamine deficiency due to poor dietary intake, impaired absorption, and increased excretion. This deficiency can result in complications such as Wernicke’s encephalopathy or Korsakoff syndrome, which are neurologic conditions associated with thiamine depletion. Including thiamine-rich foods like pork in the diet helps to replenish this essential vitamin and minimize such complications.

Think of thiamine as fuel for the body's energy-generating engine. In cirrhosis, the engine is already struggling, and without enough fuel (thiamine), it might break down completely, leading to neurologic and metabolic complications.

Nurse Jenna should educate the client about incorporating thiamine-rich foods into their diet and emphasize the importance of maintaining adequate nutrition.

• Provide a list of thiamine-rich foods, including pork, whole grains, legumes, nuts, and seeds, to promote dietary variety.
• Advise the client to avoid alcohol, as it depletes thiamine levels and worsens liver damage.
• Encourage regular follow-ups to monitor liver function and nutritional status, ensuring that vitamin deficiencies are promptly identified and treated.
• Collaborate with a dietitian to create a balanced meal plan tailored to the client’s needs and liver function limitations.
• Monitor for signs of thiamine deficiency, such as confusion, ataxia, and memory loss, and ensure timely medical intervention if these occur.

✘Incorrect answer options:

Broccoli: While broccoli is a healthy food rich in vitamins such as vitamin C and fiber, it is not a significant source of thiamine. It can be part of a well-balanced diet but does not address the specific need for thiamine replenishment.

Milk: Milk contains small amounts of thiamine but is not considered a rich source. It is better known for its calcium and vitamin D content, which are beneficial for bone health but not sufficient to correct a thiamine deficiency.

Chicken: Chicken contains some thiamine, but it is not as concentrated as in pork. While chicken is a good source of protein, it is not the best option for maximizing thiamine intake compared to pork.

EXPLANATION

✔Correct answer:

Elevate the scrotum for support. Swelling in the scrotal area is a common occurrence after an inguinal hernia repair, particularly in male clients. To reduce swelling and provide comfort, Nurse David should advise Mr. Harris to elevate the scrotum. This can be done by wearing supportive underwear (such as a scrotal support or snug briefs) or placing a rolled towel under the scrotum while lying down. Elevating the scrotum improves venous return, minimizes fluid accumulation, and reduces discomfort.

Swelling in the scrotum may result from manipulation during surgery or from temporary disruption of lymphatic and venous drainage. Elevation is a simple, non-invasive way to manage this issue effectively and promote faster recovery.

Think of the scrotum after surgery like a balloon filled with water that has been set down. If the balloon stays flat on a surface, the water pools at the bottom, increasing pressure and making it swell. Elevating the balloon allows the water to flow more evenly, reducing the pressure and preventing extra swelling. Similarly, elevating the scrotum after an inguinal hernia repair helps reduce fluid accumulation and swelling, making recovery more comfortable.

In addition to scrotal elevation, Nurse David should provide Mr. Harris with general postoperative care instructions to ensure optimal recovery.

• Encourage the client to avoid heavy lifting, straining, or activities that increase intra-abdominal pressure for at least 4–6 weeks.
• Apply ice packs to the surgical site intermittently during the first 24–48 hours to reduce swelling and pain.
• Advise wearing supportive briefs or scrotal supports to minimize discomfort while ambulating.
• Educate the client on signs of complications, such as increased pain, redness, or drainage at the surgical site, and advise seeking medical attention if these occur.
• Encourage light walking as tolerated to promote circulation and prevent venous stasis or blood clots.

✘Incorrect answer options:

Use heat therapy on the abdomen: Heat therapy is not recommended immediately after hernia repair surgery. Heat can increase blood flow and potentially worsen swelling. Ice packs are a more appropriate choice to reduce swelling in the early postoperative period.

Stick to a low-fiber diet: A low-fiber diet is not necessary after hernia repair. In fact, a high-fiber diet is encouraged to prevent constipation, which can lead to straining and increased intra-abdominal pressure—factors that may compromise the surgical site.

Restrict fluid intake: Fluid restriction is not necessary after hernia repair. Adequate hydration is important for overall recovery and helps soften stools, reducing the risk of straining during bowel movements.

EXPLANATION

✔Correct answer:

Pause the irrigation temporarily. Abdominal cramping during colostomy irrigation is a common occurrence and is typically caused by infusing the solution too quickly or using a solution that is too cold. The most appropriate action for Nurse Paul is to pause the irrigation temporarily, allowing the client’s muscles to relax and the cramping to subside. Once the cramping has resolved, Nurse Paul can resume the irrigation at a slower rate, ensuring the solution is at body temperature to prevent further discomfort.

Cramping is usually not a serious concern, but failing to address it can lead to discomfort or resistance from the client in continuing the procedure. Adjusting the speed and technique of irrigation can prevent further issues and ensure the procedure is successful.

Imagine trying to drink water too fast through a straw, causing your throat to feel uncomfortable. If you pause and drink more slowly, the discomfort eases. Similarly, pausing the irrigation allows the body to adjust and reduces cramping.

Nurse Paul should focus on ensuring that the irrigation process is comfortable and effective by adjusting the technique and addressing the client’s concerns.

• Pause the irrigation as soon as the client reports cramping to allow the abdominal muscles to relax.
• Ensure the irrigation solution is at body temperature, as cold solutions can exacerbate cramping.
• Restart the irrigation at a slower rate to prevent further discomfort and improve the client’s tolerance to the procedure.
• Assess for other potential causes of cramping, such as excessive pressure from the irrigation bag being too high.
• Educate the client about what to expect during colostomy irrigation, reassuring them that cramping is a common and manageable occurrence.

✘Incorrect answer options:

Raise the height of the irrigation to improve flow: Raising the height of the irrigation bag increases the flow rate, which would likely worsen abdominal cramping. The bag should be kept at an appropriate height (approximately 18–24 inches above the stoma) to ensure a steady, gentle flow.

Inform the physician about the cramping: Cramping during colostomy irrigation is usually a self-limiting and expected occurrence, easily managed by adjusting the procedure. It does not require immediate notification of the physician unless the cramping persists despite proper technique or is accompanied by other concerning symptoms.

Administer pain medication and continue the irrigation: Administering pain medication is not necessary for managing cramping during colostomy irrigation. Cramping can be relieved by pausing the procedure and addressing the technique. Continuing the irrigation without addressing the cramping would cause further discomfort.

EXPLANATION

✔Correct answer:

Listen to bowel sounds across all quadrants. In an abdominal assessment, the proper sequence is inspection, followed by auscultation, percussion, and then palpation. This order is critical because palpation and percussion can stimulate bowel activity, potentially altering the bowel sounds and leading to inaccurate findings. Therefore, after inspecting the skin of the abdomen, Nurse Carla should listen to bowel sounds across all four quadrants using a stethoscope to assess the frequency and quality of intestinal activity.

Auscultation allows the nurse to identify hypoactive, hyperactive, or absent bowel sounds, which may indicate underlying issues such as ileus, obstruction, or increased motility. This step provides crucial information before moving on to techniques that may interfere with the natural activity of the gastrointestinal system.

Think of auscultating the abdomen like listening to an engine before touching it. If you start poking around (palpation) or tapping on it (percussion) first, the engine’s natural sound may change, making it harder to diagnose any issues.

During an abdominal assessment, it is important to follow the correct sequence to obtain accurate results and prevent errors in interpretation.

• Auscultate all four quadrants using the diaphragm of the stethoscope, starting in the right lower quadrant (RLQ) where bowel sounds are usually most active.
• Listen for at least 5 minutes in each quadrant if bowel sounds are absent before concluding they are truly absent.
• Document the character of bowel sounds (e.g., hypoactive, hyperactive, normal, absent).
• Avoid pressing the stethoscope too firmly, as this can inadvertently stimulate bowel activity.
• Ensure a quiet environment during auscultation to avoid interference from external noises.

✘Incorrect answer options:

Perform percussion in the right lower quadrant: Percussion is performed later in the abdominal assessment sequence, after auscultation, to assess for fluid, gas, or organ enlargement. It should not precede auscultation because it could stimulate bowel activity and alter the bowel sounds.

Palpate the liver at the margin of the right ribs: Palpation is the final step in the abdominal assessment. Palpating the liver or other structures too early may induce discomfort or change bowel sounds, leading to inaccurate auscultation findings.

Palpate the abdomen to assess size: Similar to liver palpation, general palpation should be done after auscultation and percussion to prevent stimulation of bowel sounds or discomfort that might skew findings.

EXPLANATION

✔Correct answer:

"You seem really upset about this." This response is the most therapeutic because it validates Arthur’s emotions and opens the door for him to express his fears and concerns. Acknowledging a patient’s feelings shows empathy and creates a supportive environment. By reflecting his emotional state, the nurse encourages further communication, helping Arthur feel heard and understood without making assumptions or dismissing his concerns. This approach aligns with patient-centered care and therapeutic communication principles, which emphasize listening and providing emotional support.

By addressing the patient's emotional state, the nurse can better understand Arthur’s thoughts, assess his fears, and provide appropriate education or reassurance based on the specific situation.

Imagine a friend saying they feel terrible about a problem. Instead of jumping to conclusions or offering solutions, you might say, "You seem really upset about this." This encourages them to open up, helping you understand their feelings better without invalidating their concerns.

Nurse interventions should focus on active listening and providing emotional support to help Arthur cope with his fear of a possible cancer diagnosis.

• Use open-ended and reflective statements to encourage the patient to express their feelings, such as, "Can you tell me more about why you feel this way?"
• Offer reassurance that his concerns will be addressed, but avoid giving false hope or making definitive statements about the diagnosis.
• Provide education about the purpose and process of the sigmoidoscopy, emphasizing that it is a diagnostic procedure to help rule out or confirm issues, not a confirmation of cancer.
• Assess for underlying anxiety or depression and refer Arthur to counseling or support groups if needed to help him cope with his fears.
• Remain present and actively listen to his concerns without interrupting or redirecting the conversation prematurely.

✘Incorrect answer options:

"Oh, don’t worry about it; everything will be just fine.": This response is dismissive and invalidates Arthur’s feelings. It provides false reassurance and may discourage him from further expressing his fears or concerns.

"Why do you think you have cancer?": While this question explores Arthur’s thoughts, it lacks emotional validation. It could make him feel defensive or that he needs to justify his feelings, rather than addressing his emotional distress.

"I know exactly how you feel.": This response is not therapeutic because it assumes the nurse understands Arthur’s unique experience, which may not be true. It can come across as minimizing his feelings or shifting the focus to the nurse instead of the patient.

EXPLANATION

✔Correct answer:

Cut the wafer opening 1/8 inch larger than the stoma to prevent irritation. Nurse Clara should instruct Mr. Reynolds to cut the wafer opening 1/8 inch larger than the stoma to ensure a proper fit without irritating the stoma. This small gap allows for movement of the stoma (which may expand or contract slightly due to peristalsis) and prevents the wafer from rubbing against or constricting the stoma, which could cause irritation or damage. A snug yet slightly larger opening also protects the peristomal skin from exposure to stool, reducing the risk of skin breakdown and infection.

A correctly cut wafer helps create a secure seal, prevents leaks, and promotes comfort, ensuring the ostomy appliance works effectively while protecting the client’s skin.

Think of the wafer opening as a frame around a painting. If the frame is too tight, it might damage the edges of the painting (stoma). A small gap around the edges provides just enough space for protection without leaving the painting (skin) exposed to harm.

Proper wafer measurement and cutting are critical aspects of ostomy self-care. Nurse Clara should teach and evaluate Mr. Reynolds' technique to ensure correct application.

• Teach the client to use a stoma measuring guide (often included in ostomy care kits) to measure the stoma's size accurately before cutting the wafer.
• Instruct the client to trace the measured size onto the wafer before cutting to ensure accuracy.
• Educate the client on the importance of a secure seal to prevent stool leakage onto the peristomal skin, which can cause irritation and breakdown.
• Monitor for signs of skin irritation or breakdown around the stoma and provide strategies to address these issues, such as using a skin barrier or barrier rings.
• Encourage the client to periodically re-measure the stoma, especially in the weeks following surgery, as the stoma size may change during the healing process.

✘Incorrect answer options:

Cut the wafer opening exactly to the size of the stoma to ensure a snug fit: Cutting the wafer exactly to the size of the stoma would cause the wafer to rub against the stoma, leading to irritation, bleeding, or damage. A small gap is necessary to allow for stoma movement and prevent these complications.

Cut the wafer opening 1/4 inch larger than the stoma to allow for swelling: While a small allowance is necessary, cutting the wafer 1/4 inch larger than the stoma would leave too much peristomal skin exposed, increasing the risk of irritation and stool leakage.

Cut the wafer opening 1/2 inch larger than the stoma to maximize airflow: A 1/2-inch gap is excessively large and would result in significant skin exposure to stool, increasing the likelihood of skin breakdown and infection. Airflow is not a concern for proper stoma care; a snug fit is the priority.

EXPLANATION

✔Correct answer:

A rigid, board-like abdomen. A rigid, board-like abdomen is a classic sign of perforation, a serious and potentially life-threatening complication of a peptic ulcer. When a peptic ulcer perforates, gastric or duodenal contents (including acid, bile, and partially digested food) spill into the peritoneal cavity, causing chemical peritonitis and inflammation. This leads to severe abdominal pain and muscle rigidity, often described as "board-like," as the body attempts to guard the inflamed area.

Perforation is a surgical emergency requiring immediate intervention to prevent sepsis and further complications. Other associated signs may include tachycardia, fever, hypotension, and rebound tenderness.

Think of the stomach as a water balloon. If the balloon bursts (perforation), its contents spill into the surrounding area, causing irritation and inflammation. The rigid abdomen is the body’s "alarm system" signaling this serious event.

Nurse Rachel must act quickly upon recognizing signs of perforation, as delay in treatment can lead to severe complications like peritonitis or septic shock.

• Notify the healthcare provider immediately and prepare the client for possible emergency surgery.
• Monitor vital signs for signs of shock, such as hypotension, tachycardia, and fever.
• Ensure the client is kept NPO (nothing by mouth) to prevent further gastric contents from entering the peritoneal cavity.
• Administer IV fluids and prescribed medications, such as antibiotics, to prevent or treat infection.
• Provide emotional support to the client and family, as this complication can be frightening and life-threatening.

✘Incorrect answer options:

Nausea and vomiting: While nausea and vomiting are common symptoms of peptic ulcer disease, they are not specific to perforation. These symptoms are more often associated with gastritis, partial gastric outlet obstruction, or other gastrointestinal disorders.

Bradycardia: Bradycardia is not typically associated with perforation. Instead, tachycardia (rapid heart rate) is a more common finding as the body responds to pain, inflammation, and possible hypovolemia from peritoneal irritation.

Numbness in the legs: Numbness in the legs is unrelated to peptic ulcer perforation and is more likely associated with neurological conditions such as nerve compression or neuropathy. It does not indicate gastrointestinal complications.

EXPLANATION

✔Correct answer:

Administer the bolus tube feeding as planned since 150 mL is a safe residual volume. Gastric residual volume (GRV) is used as an indicator of gastric emptying and tolerance to enteral feeding. Current clinical guidelines recommend continuing tube feedings as planned if the GRV is below 200-500 mL, depending on institutional protocols. A GRV of 150 mL is considered safe, as it does not indicate delayed gastric emptying or an increased risk for aspiration. Discontinuing feedings unnecessarily could interrupt the patient's nutritional support and lead to malnutrition or delayed healing.

In patients with nasogastric or other feeding tubes, gastric motility and emptying are monitored to ensure the stomach can handle both its normal secretions and the administered enteral nutrition. A GRV within a safe threshold indicates that the stomach is adequately processing the feedings without significant retention, minimizing the risk of regurgitation and aspiration.

Think of the stomach as a storage tank. If the tank is not overly full, you can safely add more liquid (feeding). However, if the tank is too full, adding more could cause an overflow (aspiration risk). In this case, a "tank" at 150 mL is well within safe limits for adding more nutrition.

When administering tube feedings, always follow evidence-based guidelines for patient safety and optimal nutrition.

• Confirm that the GRV is within the safe limit per facility policy before proceeding with the feeding.
• Ensure proper positioning of the patient, keeping the head of the bed elevated at least 30-45 degrees during and after feeding to prevent aspiration.
• Flush the nasogastric tube with water before and after feeding to maintain patency and hydration.
• Monitor for signs of intolerance to the feeding, such as nausea, vomiting, or abdominal distension.
• Document the GRV, feeding details, and any patient response as part of routine care.

✘Incorrect answer options:

Discard the residual volume to prevent aspiration, then administer the bolus feeding. Discarding gastric residual volume is generally not recommended unless specified by a healthcare provider. Retained gastric contents include important digestive enzymes and nutrients, and discarding them could lead to nutritional and electrolyte imbalances.

Hold the feeding and notify the healthcare provider immediately. While holding feedings and notifying the provider may be appropriate for very high GRV levels (e.g., >500 mL, depending on policy), a GRV of 150 mL is within the normal range and does not warrant such an action. This approach would unnecessarily delay nutrition without clinical justification.

Reassess the residual volume in 15-30 minutes, then proceed if it remains unchanged. Reassessing GRV at this level is unnecessary and would cause delays in delivering nutrition. A GRV of 150 mL does not indicate impaired gastric emptying, so there is no need to wait and reassess.

EXPLANATION

✔Correct answer:

Approximately 1500 mL. Within the first 24 hours following ileostomy surgery, it is normal for the output to be approximately 1500 mL of liquid stool. This occurs because the ileum (the final portion of the small intestine) is responsible for absorbing water and nutrients, and its function is disrupted postoperatively. The surgical creation of an ileostomy bypasses the colon, which is the main site for water reabsorption. As a result, the initial output is high-volume and liquid in consistency.

Over time (a few weeks to months), the small intestine adapts, and the ileostomy output typically decreases to 500–1000 mL per day and becomes thicker as the body adjusts to the absence of the colon’s absorptive role.

Think of the ileum as a pipe that has just started draining without a water filter (the colon). Initially, everything flows out rapidly, but as the pipe adjusts, it regulates and slows down, resulting in less liquid passing through.

Nurse Taylor should monitor the ileostomy output closely, as excessive fluid loss can lead to dehydration and electrolyte imbalances.

• Measure and record the ileostomy output every 4–8 hours to assess fluid balance and detect any abnormalities.
• Monitor for signs of dehydration, such as dry mucous membranes, decreased urine output, tachycardia, or hypotension, and intervene promptly.
• Encourage the client to drink adequate fluids to replace the high volume of output, aiming for at least 2–3 liters of fluid daily unless contraindicated.
• Monitor electrolyte levels, particularly sodium and potassium, which are commonly depleted due to high ileostomy output.
• Educate the client about the importance of hydration and the gradual adjustment of output over time as the small intestine adapts.

✘Incorrect answer options:

Approximately 100 mL: This is too low for the first 24 hours after ileostomy surgery. The absence of the colon’s water reabsorption function leads to high initial output, not minimal output.

Approximately 500 mL: While 500 mL may be closer to the long-term daily ileostomy output after adaptation, it is too low for the immediate postoperative period, where output is much higher.

Approximately 5000 mL: This volume far exceeds normal ileostomy output and would indicate severe complications, such as high-output ileostomy or small bowel obstruction. Such excessive loss would require immediate medical intervention to prevent life-threatening dehydration and electrolyte imbalances.

EXPLANATION

✔Correct answer:

A pH reading of 3.5. Gastric contents typically have an acidic pH, generally ranging between 1 and 5, depending on factors like recent food intake and medications (e.g., antacids or proton pump inhibitors). A pH reading of 3.5 strongly suggests that the nasogastric (NG) tube is correctly positioned in the stomach, as the acidic environment indicates the presence of gastric secretions.

pH testing is a widely used bedside method for confirming NG tube placement, as gastric aspirate is distinctly acidic compared to fluids from the respiratory tract or intestines. While pH measurement is a helpful indicator, it should be used alongside other verification methods (e.g., X-ray) to confirm placement and avoid complications such as misplacement into the lungs.

Key Clinical Considerations:

1. Stomach Environment: The stomach's acidic pH is due to hydrochloric acid produced by gastric parietal cells.
2. Medications and Conditions: Medications like antacids or proton pump inhibitors may increase gastric pH, and fasting may slightly alter it, but it generally remains below 5.
3. Verification: pH testing is an adjunct tool and should be supported by other methods, such as X-ray imaging, which remains the gold standard for confirming NG tube placement.

Imagine testing a lemon juice sample to confirm if it’s truly lemon juice. You expect it to be acidic (low pH). Similarly, gastric fluid from the stomach should be acidic (low pH) to confirm correct placement of the NG tube.

Ensuring proper NG tube placement is critical to prevent serious complications such as aspiration or feeding into the lungs.

• Aspirate gastric contents gently using a syringe and apply the fluid onto pH paper for measurement.
• Ensure the pH reading is in the acidic range (1-5), with most readings falling between 1-4 for a properly placed tube in the stomach.
• If the pH is not within the expected range, assess for other possible locations of the tube (e.g., respiratory tract or intestines) and use additional confirmation methods, such as X-ray.
• Evaluate the color and consistency of the aspirate, as gastric fluid is typically greenish, clear, or off-white with possible bile-stained elements.
• Document the pH value, color of aspirate, and confirmation method used in the patient’s medical record.

✘Incorrect answer options:

A pH reading of 7.35. A pH of 7.35 represents normal blood pH, which is neutral to slightly alkaline. If aspirate from the NG tube has this pH, the tube may be in the respiratory tract, not the stomach.

A pH reading of 7.0. A pH of 7.0 is neutral and unlikely to indicate gastric placement. This reading may suggest intestinal placement or be due to diluted gastric fluid mixed with secretions from the duodenum.

A pH reading of 7.5. A pH of 7.5 is alkaline, which is inconsistent with gastric contents. This reading could indicate the tube is in the small intestine or respiratory tract. Proper verification methods are necessary in such cases to prevent complications.

EXPLANATION

✔Correct answer:

Eat six smaller meals throughout the day. After surgery to close a temporary ileostomy, it is essential for Jeff to adapt his eating habits to support recovery and ensure proper gastrointestinal function. Eating six smaller meals throughout the day helps reduce the workload on the digestive system, minimizes the risk of overloading the newly restored bowel, and prevents complications like bloating, cramping, and diarrhea. Smaller, more frequent meals are easier to digest and allow the bowel to adapt to its new function gradually.

Additionally, Jeff should consume a balanced diet with adequate nutrients, avoid foods that are difficult to digest (e.g., high-fiber or greasy foods initially), and ensure proper hydration to support healthy bowel movements. Over time, his diet can be adjusted as the bowel adapts, based on tolerance.

Think of the bowel as a conveyor belt in a factory. If too much material (food) is put on the belt at once, it can get overloaded and jammed. Smaller, frequent "deliveries" keep everything running smoothly and allow for gradual adaptation after surgery.

Nurse Williams should provide tailored dietary education and practical strategies to help Jeff manage his nutrition effectively after ileostomy closure.

• Encourage Jeff to eat six small meals spread evenly throughout the day to avoid overloading the bowel and to promote gradual adaptation.
• Advise him to chew food thoroughly and eat slowly to aid digestion and prevent discomfort or blockages.
• Educate Jeff about reintroducing high-fiber foods gradually, as these can be more challenging to digest initially after surgery.
• Encourage him to maintain adequate hydration by drinking 2–3 liters of fluid daily, as water is essential for healthy bowel function and preventing dehydration.
• Discuss foods to avoid temporarily, such as carbonated drinks, spicy foods, and foods known to cause gas or bloating (e.g., beans, cabbage, and onions).
• Monitor for signs of complications, such as abdominal pain, diarrhea, or constipation, and instruct Jeff to report these symptoms promptly.

✘Incorrect answer options:

Consume the largest meal of the day in the evening: Eating a large meal in the evening can overload the bowel and lead to discomfort, cramping, or bloating. Smaller, more frequent meals throughout the day are better suited for recovery and adaptation.

Maintain regular eating habits without modification: Following surgery, modifications to eating habits are necessary to allow the bowel to adapt and to prevent complications. Regular eating habits may not accommodate the body's altered digestive function.

Limit fluid intake to prevent complications: Limiting fluid intake can lead to dehydration, which is a significant concern after ileostomy closure due to changes in bowel absorption. Instead, Jeff should ensure he stays well-hydrated by drinking 2–3 liters of fluid daily.

EXPLANATION

✔Correct answer:

Consume meals while sitting upright. For patients with achalasia, eating while sitting upright is crucial because it takes advantage of gravity to help food pass through the esophagus and into the stomach more easily. Achalasia is characterized by impaired peristalsis and failure of the lower esophageal sphincter (LES) to relax, which can lead to dysphagia (difficulty swallowing), regurgitation, and weight loss. Sitting upright during meals reduces the risk of food retention in the esophagus, minimizes regurgitation, and facilitates the movement of food through the esophagus.

This simple positional strategy helps improve nutrition by ensuring better swallowing and digestion while reducing the discomfort associated with achalasia.

Think of food traveling down the esophagus like marbles rolling down a ramp. If the ramp is tilted upright, the marbles flow smoothly with gravity’s help. Similarly, sitting upright during meals allows gravity to assist food in moving into the stomach.

Student Nurse Mia should include additional strategies to enhance the patient's comfort and improve nutritional intake.

• Encourage the patient to eat slowly, take small bites, and chew food thoroughly to reduce the risk of choking and improve swallowing efficiency.
• Recommend small, frequent meals instead of large meals to minimize esophageal discomfort and reduce pressure on the LES.
• Advise the patient to avoid lying down immediately after eating; instead, remain upright for at least 1 hour to reduce regurgitation and aid digestion.
• Suggest incorporating soft, moist, and easily digestible foods, such as pureed or mashed foods, to minimize the effort required for swallowing.
• Educate the patient about sipping warm liquids before meals, which may help relax the LES and facilitate swallowing.

✘Incorrect answer options:

Refrain from drinking fluids during meals: Drinking fluids during meals can actually assist in washing down food and preventing it from getting stuck in the esophagus. This recommendation would be counterproductive for patients with achalasia.

Eliminate soft and semi-soft foods from the diet: Soft and semi-soft foods are often recommended for achalasia patients because they are easier to swallow and less likely to cause esophageal discomfort compared to hard or dry foods. Eliminating these foods would worsen symptoms and nutritional intake.

Lean forward while swallowing foods: Leaning forward during meals is not recommended, as it can exacerbate difficulty swallowing and increase the risk of regurgitation. Maintaining an upright position is the preferred strategy.

EXPLANATION

✔Correct answer:

Indomethacin (Indocin). Indomethacin, a nonsteroidal anti-inflammatory drug (NSAID), is known to irritate the gastric mucosa and can exacerbate acute gastritis. NSAIDs inhibit prostaglandin synthesis, which reduces the protective mucosal lining of the stomach, making it more susceptible to irritation, inflammation, and even ulceration. Prostaglandins normally help to maintain the gastric mucosal barrier by promoting mucus and bicarbonate production and maintaining adequate blood flow to the stomach lining. In clients with acute gastritis, NSAIDs like indomethacin can worsen symptoms such as pain, nausea, and gastric bleeding.

Nurse Karen should question the use of this medication and discuss alternative pain management options with the healthcare provider, especially since the client's current condition involves inflammation of the gastric mucosa.

Think of the stomach lining as a protective raincoat. NSAIDs like indomethacin poke holes in the raincoat, leaving the stomach vulnerable to the "acid rain" (gastric acid), which worsens the inflammation in acute gastritis.

Nurse Karen should focus on protecting the gastric mucosa while ensuring adequate pain or inflammation management for the client.

• Educate the client about the risks of NSAID use, particularly in the context of gastric conditions like acute gastritis.
• Monitor for signs of gastrointestinal bleeding, such as black, tarry stools or coffee-ground emesis, which are complications of NSAID use in gastritis.
• Collaborate with the healthcare provider to explore alternative pain management options, such as acetaminophen, which is less likely to irritate the stomach lining.
• Administer prescribed medications that protect the gastric mucosa, such as proton pump inhibitors (PPIs) or H2 receptor blockers, as ordered.
• Encourage the client to avoid other gastric irritants, such as alcohol, caffeine, and spicy foods, to promote healing of the gastric mucosa.

✘Incorrect answer options:

Digoxin (Lanoxin): Digoxin, a cardiac glycoside, is not typically associated with gastric mucosal irritation. However, it requires careful monitoring for toxicity, especially in clients with reduced gastric absorption, but it does not exacerbate gastritis.

Propranolol hydrochloride (Inderal): Propranolol, a beta-blocker, is not known to irritate the gastric lining. It is used primarily to manage conditions such as hypertension, angina, or arrhythmias and does not pose a direct risk to clients with gastritis.

Furosemide (Lasix): Furosemide, a loop diuretic, does not irritate the gastric mucosa and is not directly linked to worsening gastritis. However, it can cause electrolyte imbalances and dehydration, which should be monitored in clients with other gastrointestinal conditions.

EXPLANATION

✔Correct answer:

Vitamin B12. Chronic gastritis, especially when caused by autoimmune processes or Helicobacter pylori infection, can lead to damage of the gastric mucosa. This damage often results in a decrease or loss of intrinsic factor production by the parietal cells in the stomach. Intrinsic factor is essential for the absorption of vitamin B12 in the ileum. A deficiency in vitamin B12 can lead to pernicious anemia, which is characterized by symptoms such as fatigue, pallor, glossitis (inflamed tongue), paresthesia (tingling or numbness), and cognitive changes.

Without adequate B12, the body cannot properly produce red blood cells, leading to megaloblastic anemia. This vitamin deficiency is particularly important to monitor in clients with chronic gastritis because it can cause long-term neurological complications if left untreated.

Imagine a key (intrinsic factor) is required to unlock a door to absorb vitamin B12. In chronic gastritis, the key is lost because the stomach lining is damaged, so B12 cannot "enter the body," leading to deficiency.

Nurses should monitor clients with chronic gastritis for signs of vitamin B12 deficiency and educate them on management and prevention strategies.

• Assess for clinical symptoms of B12 deficiency, such as fatigue, pallor, glossitis, numbness, or balance issues.
• Monitor laboratory results, including complete blood count (CBC), serum B12 levels, and methylmalonic acid (MMA) levels, which indicate B12 deficiency.
• Administer vitamin B12 supplements as prescribed, either orally or via intramuscular injections in cases of intrinsic factor deficiency.
• Educate the client on the importance of a balanced diet rich in B12 sources, such as meat, fish, dairy, and fortified cereals, if intrinsic factor production is intact.
• Collaborate with a dietitian to develop a nutrition plan for clients with chronic gastritis and associated deficiencies.

✘Incorrect answer options:

Vitamin C: While vitamin C is important for overall health and immune function, its deficiency (leading to scurvy) is not directly linked to chronic gastritis. Gastritis does not typically interfere with the absorption of vitamin C.

Vitamin A: Vitamin A deficiency is uncommon in gastritis. It is typically associated with fat malabsorption conditions or dietary insufficiencies, not with intrinsic factor loss or gastric mucosal damage.

Vitamin E: Like vitamin A, vitamin E is a fat-soluble vitamin and is not affected by conditions involving gastric intrinsic factor or chronic gastritis. Its deficiency is rare and typically related to severe fat malabsorption disorders.

EXPLANATION

✔Correct answer:

300 units/L. In chronic pancreatitis, serum amylase levels can sometimes be mildly elevated depending on the stage and extent of pancreatic damage. While enzyme levels are usually less elevated than in acute pancreatitis, some patients with chronic pancreatitis still show moderately elevated amylase levels (e.g., around 300 units/L). This occurs during exacerbations of chronic inflammation or when pancreatic tissue continues to be destroyed, releasing residual enzymes into the bloodstream.

This distinguishes chronic pancreatitis from acute pancreatitis, where amylase levels are often markedly elevated (typically three or more times the upper limit of normal). A value like 300 units/L suggests mild to moderate inflammation, which is consistent with the chronic condition.

Imagine the pancreas as a factory producing digestive enzymes. In acute pancreatitis, the factory overproduces and floods the bloodstream with enzymes (very high levels). In chronic pancreatitis, the factory is damaged but still functions to some extent, leading to moderate enzyme leakage during flare-ups (mild to moderate elevations).

Management of chronic pancreatitis focuses on symptom relief, preventing exacerbations, and monitoring laboratory trends to assess disease progression and treatment effectiveness. Nurses play a crucial role in providing holistic care.

• Educate the patient on avoiding triggers, such as alcohol and high-fat foods, to prevent flare-ups.
• Monitor enzyme levels (e.g., amylase, lipase) periodically to identify trends or potential complications like acute-on-chronic pancreatitis.
• Provide pancreatic enzyme replacement therapy as prescribed to aid digestion and reduce malabsorption symptoms.
• Support the patient in managing chronic pain, which is common in chronic pancreatitis, and encourage non-opioid pain management strategies when feasible.
• Assess for complications such as diabetes mellitus and malnutrition, which are common in advanced cases of chronic pancreatitis.

✘Incorrect answer options:

100 units/L: This value is within or near the normal range for serum amylase (30–110 units/L) and is not typically seen in active chronic pancreatitis with inflammation or flare-ups. While amylase levels may normalize in late-stage chronic pancreatitis due to extensive tissue damage, this is less likely in early or moderate stages where moderate elevations like 300 units/L are more common.

45 units/L: This is a low-normal value for serum amylase. Such a low level may suggest significant pancreatic insufficiency or advanced chronic pancreatitis with complete enzyme depletion. It does not reflect the moderate enzyme elevation that is often observed during flare-ups or mild inflammation in chronic pancreatitis.

500 units/L: A serum amylase level of 500 units/L is highly elevated and typically seen in acute pancreatitis or other acute conditions like pancreatic duct obstruction or perforation. This is inconsistent with the more moderate elevations characteristic of chronic pancreatitis.

EXPLANATION

✔Correct answer:

The procedure is completed in two stages. An ileoanal reservoir procedure (also known as a J-pouch surgery) is a surgical treatment for ulcerative colitis or familial adenomatous polyposis. It is typically completed in two stages. During the first stage, the colon and rectum are removed, and a reservoir (J-pouch) is created from the ileum (the last portion of the small intestine). The ileum is then connected to the anal canal, allowing the patient to maintain continence and defecate through the anus. During this stage, a temporary ileostomy is created to divert stool and allow the reservoir to heal.

In the second stage, which is usually performed 2–3 months after the first, the temporary ileostomy is reversed, and stool is redirected to pass through the new reservoir. The two-stage process allows the ileoanal reservoir to heal properly before it is used.

Imagine building a new drainage system (the J-pouch). First, you construct and test the pipes while temporarily diverting the flow (stage one). Once the pipes are secure and working well, you reconnect the system (stage two) for normal function.

Nurse Franklin should ensure that Gertrude understands the procedure, its stages, and the temporary nature of the ileostomy to alleviate any fears or misconceptions.

• Explain that the first stage involves creating the J-pouch and a temporary ileostomy to allow healing.
• Reassure the patient that the ileostomy is temporary and will be reversed in the second surgery, typically after 2–3 months.
• Educate the patient about managing the temporary ileostomy, including stoma care and recognizing signs of complications such as infection or dehydration.
• Discuss the expected bowel function after the final surgery, including possible increased frequency of stools initially and eventual adjustment to fewer bowel movements.
• Provide emotional support and refer the patient to an ostomy support group, if needed, to help with coping and adjustment.

✘Incorrect answer options:

A permanent ileostomy will be created: This is incorrect because an ileoanal reservoir procedure is designed to preserve normal defecation through the anus. A permanent ileostomy is not the goal of this surgery, although it may be necessary in some cases if complications arise.

A reservoir will exit through the abdominal wall: This is incorrect because the ileoanal reservoir is created internally and connects to the anal canal, not the abdominal wall. The temporary ileostomy, not the reservoir, exits through the abdominal wall during the healing phase.

A second surgery will be performed 12 months later: This is inaccurate, as the second surgery (ileostomy reversal) is usually performed 2–3 months after the first surgery, not 12 months later.

EXPLANATION

✔Correct answer:

Disturbed body image. After the creation of a colostomy, disturbed body image is often a priority nursing diagnosis for clients, as the procedure involves a significant alteration in physical appearance and bodily function. Many clients struggle with adjusting to the presence of a colostomy bag, which can lead to feelings of embarrassment, shame, or self-consciousness. This can significantly impact their emotional well-being and their ability to accept and adapt to the changes in their body. Addressing body image concerns early in the postoperative period is crucial to supporting the client’s psychological adjustment, promoting self-esteem, and improving their ability to care for the colostomy independently.

Nurse John should provide education, emotional support, and opportunities for the client to express their feelings about their body changes. Gradually involving the client in colostomy care helps build confidence and a sense of control over the new situation.

Imagine a person learning to live with a visible scar on their face after surgery. At first, they might feel embarrassed or avoid social interactions. Similarly, a client with a colostomy may feel self-conscious about the visible changes and need time, support, and guidance to regain confidence.

Nurse John should include interventions that address the client’s emotional and physical adjustment to life with a colostomy.

• Encourage the client to express their feelings about the colostomy and provide reassurance and emotional support.
• Educate the client on proper colostomy care, including cleaning, emptying the bag, and managing potential odors, to help build confidence in self-care.
• Introduce the client to support groups or resources, such as organizations for ostomy patients, to provide peer support and reduce feelings of isolation.
• Reinforce positive coping strategies and celebrate small successes as the client becomes more comfortable with their colostomy.
• Involve family members in education and support if the client agrees, as they can play a critical role in providing encouragement and assistance.

✘Incorrect answer options:

Imbalanced nutrition: more than body requirements: While nutrition may need to be monitored after a colostomy, this diagnosis is not typically prioritized. Clients with colostomies are more likely to experience issues related to imbalanced nutrition: less than body requirements due to changes in dietary habits, but this would only be addressed if specific nutritional concerns arise.

Sexual dysfunction: While sexual dysfunction may be a concern for some clients with colostomies, it is generally addressed later in recovery once the client has adapted to their colostomy and regained confidence in their body image. It is not the initial priority unless the client specifically raises concerns about intimacy.

Fear related to poor prognosis: Fear related to a poor prognosis is not typically a primary concern for clients with a colostomy unless it is associated with a terminal or severe underlying condition, such as advanced cancer. For most clients, body image and lifestyle adjustment concerns take precedence postoperatively.

EXPLANATION

✔Correct answer:

A pair of scissors for emergency cutting. When a Sengstaken-Blakemore tube is in use for the management of esophageal varices, there is a risk of airway obstruction or respiratory compromise, particularly if the gastric balloon migrates upward and compresses the trachea. To prevent life-threatening complications such as asphyxiation, it is essential to have a pair of scissors at the bedside at all times. The scissors allow for rapid deflation of the balloon by cutting the tubing in an emergency situation, thereby restoring the airway.

The Sengstaken-Blakemore tube is a specialized device with inflatable balloons used to compress bleeding esophageal varices. However, its use requires careful monitoring and preparation for emergencies due to the high-risk nature of the procedure and the potential for complications.

Imagine a bicycle tire with an air valve that's overinflated and at risk of bursting. If the tire shifts and starts pressing against the chain (blocking movement), you would need a tool to quickly release the air and prevent damage. In the case of the Sengstaken-Blakemore tube, the inflated balloons can act like the overinflated tire, potentially compressing the airway (chain). The scissors at the bedside are your emergency tool to "release the air" by cutting the tube, ensuring the airway is not obstructed and preventing a life-threatening situation.

Nurses caring for clients with a Sengstaken-Blakemore tube must prioritize airway safety, effective monitoring, and preparation for emergencies.

• Ensure a pair of scissors is always available at the bedside to cut the tube if airway obstruction occurs.
• Monitor for signs of respiratory distress, such as cyanosis, decreased oxygen saturation, or difficulty breathing.
• Check balloon pressures as per protocol to avoid overinflation, which increases the risk of rupture or displacement.
• Provide suctioning as needed to prevent aspiration of saliva or blood.
• Reassure and educate the client about the purpose of the tube and the safety measures in place to prevent complications.

✘Incorrect answer options:

An irrigation set for the tube: While irrigation may be necessary to clear clots or secretions from the gastric lumen, it is not the most critical item to keep at the bedside. Irrigation does not address airway emergencies, which are a priority in clients with a Sengstaken-Blakemore tube.

A Kelly clamp for tube adjustment: Kelly clamps may be used to secure or adjust tubing, but they are not suitable for addressing airway emergencies. Clamping the tube would not resolve a situation where the airway is compromised due to balloon displacement.

An obturator for tube reinsertion: An obturator is typically associated with tracheostomy tubes, not Sengstaken-Blakemore tubes. It is not relevant in this context, as reinsertion of a Sengstaken-Blakemore tube is a specialized procedure performed by a trained provider, not managed with an obturator.

EXPLANATION

✔Correct answer:

Hepatitis A. Hepatitis A is most commonly transmitted through the fecal-oral route, which includes the consumption of contaminated food or water. This occurs when food is handled by individuals who are infected and do not practice proper hygiene, or when food or water sources are exposed to human feces containing the virus. Hepatitis A is an acute viral infection of the liver and does not typically lead to chronic liver disease, unlike hepatitis B or C.

Once ingested, the hepatitis A virus (HAV) travels to the liver, where it replicates within hepatocytes. The virus is then excreted in bile and eliminated through feces, which contributes to its transmission cycle. Symptoms such as jaundice, fatigue, and abdominal pain arise due to liver inflammation, but these are generally self-limiting.

Imagine someone handling raw vegetables without washing their hands after working in a garden filled with dirty compost. The unwashed vegetables can carry harmful bacteria or viruses. Similarly, Hepatitis A spreads when someone consumes food prepared by infected hands or contaminated water.

Nurses caring for a client with hepatitis A should focus on symptom management, infection prevention, and education to reduce the risk of spreading the infection.

• Educate the client and household members about proper hand hygiene and food safety practices to prevent further transmission.
• Ensure the client receives adequate hydration and rest to support liver recovery.
• Monitor liver function tests (e.g., ALT, AST, bilirubin levels) to evaluate the extent of liver inflammation and recovery progress.
• Advise against alcohol consumption to minimize further liver stress during the acute phase of illness.
• Discuss vaccination for close contacts to reduce the risk of secondary infections.

✘Incorrect answer options:

Hepatitis B: Hepatitis B is primarily transmitted through blood, sexual contact, or perinatal exposure (mother-to-child). It is not commonly associated with foodborne transmission, making it an unlikely cause in this scenario.

Hepatitis C: Hepatitis C is predominantly spread through blood-to-blood contact, such as via contaminated needles or transfusions. It is not transmitted through food, so this option does not align with the client's history.

Hepatitis D: Hepatitis D requires the presence of hepatitis B to replicate, as it is an incomplete virus. It is transmitted similarly to hepatitis B and is not associated with foodborne transmission.

EXPLANATION

✔Correct answer:

Reduce the amount of fluid consumed during meals. To help prevent dumping syndrome, clients recovering from gastrectomy are advised to limit fluid intake during meals. Dumping syndrome occurs when food moves too quickly from the stomach into the small intestine, causing symptoms like nausea, abdominal cramping, diarrhea, dizziness, and a rapid heart rate. Drinking fluids with meals accelerates gastric emptying and exacerbates dumping syndrome. Instead, clients should be encouraged to drink fluids 30 minutes to 1 hour before or after meals rather than with meals.

By separating fluid and food intake, the gastric pouch or remaining stomach can process food more slowly, preventing the rapid shift of chyme into the small intestine and minimizing the symptoms of dumping syndrome.

Imagine a funnel being used to pour both liquid and solid material into a tube. If too much liquid is added along with the solids, it causes everything to rush through the funnel too quickly, overwhelming the tube. Similarly, drinking fluids with meals can speed up gastric emptying, leading to dumping syndrome.

Nurse Brian should provide comprehensive discharge education to Mr. Lopez to manage and prevent dumping syndrome effectively.

• Advise the client to eat small, frequent meals throughout the day to reduce the risk of overwhelming the digestive system.
• Encourage the client to avoid high-sugar foods, which can contribute to rapid gastric emptying and exacerbate symptoms.
• Recommend lying down or reclining for 20–30 minutes after meals to slow gastric emptying.
• Suggest the client include high-protein, moderate-fat, and low-carbohydrate foods in meals to promote slower digestion and absorption.
• Educate the client to chew food thoroughly and eat at a slow pace to aid digestion and prevent symptoms.

✘Incorrect answer options:

Include high-carbohydrate foods in meals: High-carbohydrate foods, especially those rich in simple sugars, can worsen dumping syndrome by speeding up gastric emptying and causing an osmotic shift in the small intestine. Clients are advised to limit these foods and focus on high-protein and moderate-fat options instead.

Take a walk after eating to aid digestion: While walking after meals can be beneficial for digestion in some conditions, it is not recommended for clients with dumping syndrome. Physical activity immediately after eating may further accelerate gastric emptying and exacerbate symptoms.

Sit upright in a high-Fowler’s position while eating: While sitting upright can prevent aspiration and aid digestion in other contexts, it may increase the speed of gastric emptying in clients recovering from gastrectomy. Reclining or lying down after meals is preferred to slow the passage of food into the small intestine.

EXPLANATION

✔Correct answer:

"Provide a high-fat, low-protein diet to promote calorie intake." A high-fat diet is inappropriate for a client with acute pancreatitis, as it can stimulate the pancreas to secrete more digestive enzymes, worsening inflammation and pain. Fat digestion requires significant pancreatic enzyme activity, which is counterproductive in pancreatitis management. Instead, when the client transitions to oral intake, a low-fat, moderate-protein diet is recommended to prevent exacerbation of symptoms and promote healing. Nurse Julia should question this order as it contradicts evidence-based dietary guidelines for pancreatitis.

Clients with acute pancreatitis are typically kept NPO (nothing by mouth) initially to rest the pancreas. Once symptoms improve and oral intake is resumed, dietary advancement starts with clear liquids and progresses to a low-fat diet to minimize pancreatic stimulation.

Imagine the pancreas as an overworked machine that overheats when processing fatty foods. Feeding it a high-fat diet is like pouring fuel on the fire, causing it to work harder and worsening the "overheating." A low-fat diet allows the machine to cool down and recover.

Nurses must ensure dietary orders align with the management goals of acute pancreatitis, focusing on minimizing pancreatic stimulation and supporting recovery.

• Question dietary orders that include high-fat content or other elements that stimulate pancreatic activity.
• Educate the client about the importance of a low-fat, nutrient-balanced diet during recovery.
• Monitor for signs of intolerance to oral intake, such as abdominal pain, nausea, or vomiting, and report them promptly.
• Work with a dietitian to develop an appropriate meal plan that meets the client’s nutritional needs while minimizing pancreatic stimulation.
• Encourage small, frequent meals to reduce the digestive burden on the pancreas once oral intake is resumed.

✘Incorrect answer options:

"Administer IV fluids at 150 mL/hr to maintain hydration": This is an appropriate order, as IV fluid therapy is a cornerstone of acute pancreatitis management. It helps to maintain hydration, support circulation, and prevent complications such as hypovolemia caused by third-spacing of fluids and inflammation.

"Begin a clear liquid diet once pain subsides": Starting with a clear liquid diet after the client’s pain subsides is standard practice for advancing nutrition in pancreatitis. This helps ease the transition from NPO to oral intake while reducing pancreatic stimulation.

"Administer morphine 2 mg IV every 4 hours PRN for pain": Morphine is appropriate for managing the severe pain associated with acute pancreatitis. While there were previous concerns about morphine causing sphincter of Oddi spasm, recent evidence supports its safety and efficacy in this context.

EXPLANATION

✔Correct answer:

Irrigate the nasogastric tube. After a Billroth II procedure (gastrojejunostomy), routine nasogastric (NG) tube irrigation should be avoided unless explicitly ordered by the surgeon. Irrigating or repositioning the NG tube can disrupt the surgical anastomosis (connection between the stomach and jejunum), potentially causing complications such as leakage, perforation, or delayed healing. The NG tube is typically inserted during surgery to decompress the stomach, and its management requires strict adherence to physician-specific orders. Nurse Emily should question this order and verify it with the healthcare provider before proceeding.

Proper management of the NG tube is critical in preventing complications in clients recovering from gastric surgery. The tube should only be irrigated if there is a clear obstruction and the physician has specifically provided instructions.

Imagine a fragile bridge (the anastomosis) being built between two cliffs. Moving or disturbing the scaffolding (the NG tube) could destabilize the bridge, causing it to collapse. Similarly, improperly handling the NG tube can disrupt the healing process after surgery.

Nurses caring for a client post-Billroth II procedure should prioritize protecting the surgical site and preventing complications such as infection or anastomotic leakage.

• Monitor the NG tube output for color, consistency, and amount, and report abnormalities (e.g., blood or bile) to the surgeon.
• Ensure the NG tube is properly secured to prevent accidental displacement or tension on the anastomosis.
• Assess the client for symptoms of complications, such as abdominal distension, fever, tachycardia, or signs of dumping syndrome.
• Provide clear communication to the healthcare team regarding the need for NG tube management and follow explicit physician orders for irrigation or repositioning.
• Educate the client on the importance of following postoperative care instructions, including diet progression and activity restrictions.

✘Incorrect answer options:

Perform coughing and deep-breathing exercises: These exercises are crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially after abdominal surgery. They help maintain adequate lung expansion and oxygenation.

Encourage early ambulation: Early ambulation is appropriate and beneficial after surgery. It helps prevent complications like deep vein thrombosis (DVT), improves circulation, and promotes gastrointestinal motility, reducing the risk of ileus.

Promote leg exercises: Leg exercises, such as ankle pumps and leg lifts, are vital for preventing venous stasis and reducing the risk of DVT. They are safe and appropriate postoperatively.

EXPLANATION

✔Correct answer:

Hypotension due to reduced vascular tone and fluid shifts. Liver failure, particularly in chronic alcohol abuse, is associated with hypotension due to several factors, including reduced vascular tone, fluid shifts, and the body’s inability to regulate blood pressure effectively. In liver failure, the diseased liver cannot produce adequate levels of albumin, a protein responsible for maintaining oncotic pressure. This results in fluid leaking out of the vasculature into the interstitial spaces (ascites and peripheral edema). Additionally, liver failure is often accompanied by splanchnic vasodilation (widening of blood vessels in the abdomen) due to the release of vasodilatory substances like nitric oxide. These changes collectively lower systemic vascular resistance and lead to hypotension.

Hypotension in liver failure can be further exacerbated by decreased renal perfusion and activation of compensatory mechanisms like the renin-angiotensin-aldosterone system (RAAS), which attempt to retain sodium and water but may not fully compensate for the underlying circulatory issues.

Imagine the vascular system as a water balloon. In liver failure, it’s like the balloon has tiny holes (fluid loss) and the material has stretched out (reduced vascular tone), so the pressure inside the balloon drops, leading to hypotension.

Nurse Kate should focus on closely monitoring Mr. Brooks for hypotension and associated complications, while managing fluid balance and ensuring safety.

• Monitor blood pressure and heart rate frequently to detect hypotension and ensure timely intervention.
• Assess for signs of hypovolemia, such as dry mucous membranes, tachycardia, or decreased urine output.
• Monitor for complications of liver failure, such as ascites, hepatorenal syndrome, and spontaneous bacterial peritonitis (SBP), which can exacerbate hypotension.
• Administer prescribed albumin, diuretics (if appropriate), or vasopressors as ordered to manage fluid balance and circulatory instability.
• Educate the client and family about the importance of avoiding alcohol and adhering to dietary restrictions, such as a low-sodium diet, to minimize fluid retention and improve prognosis.

✘Incorrect answer options:

Hypertension due to increased systemic vascular resistance: Hypertension is not typically associated with liver failure. Instead, systemic vascular resistance is often reduced due to splanchnic vasodilation, leading to hypotension. Hypertension may be seen in other conditions, such as chronic kidney disease or essential hypertension, but not in liver failure.

Bradycardia due to decreased metabolic demands: Bradycardia is not commonly associated with liver failure. In fact, tachycardia is more likely as a compensatory mechanism to maintain cardiac output in the presence of hypotension and decreased blood volume.

Tachycardia due to increased cardiac output: While tachycardia can occur as a compensatory response to hypotension, liver failure is not typically characterized by increased cardiac output. Instead, it is characterized by vasodilation, fluid shifts, and reduced effective circulating blood volume, leading to hypotension.

EXPLANATION

✔Correct answer:

Sweating and pale skin. Early signs of dumping syndrome following gastric surgery often include systemic symptoms such as sweating, pale skin, dizziness, tachycardia, and a feeling of weakness. These occur because food, especially high-sugar or carbohydrate-rich food, moves too quickly from the stomach into the small intestine. This rapid gastric emptying leads to an osmotic fluid shift into the intestines, causing a sudden drop in blood volume (hypovolemia) and autonomic nervous system activation, which results in symptoms like sweating and pallor.

These symptoms typically occur within 15 to 30 minutes after eating and are characteristic of early dumping syndrome. Recognizing these signs is crucial for early intervention and management to prevent more severe episodes.

Imagine a flood caused by water being dumped too quickly into a narrow stream. The sudden rush overwhelms the system, causing turbulence downstream. Similarly, in dumping syndrome, the body reacts abruptly to the rapid influx of food into the intestines, resulting in systemic symptoms like sweating and pallor.

Nurse Sarah should monitor closely for early signs of dumping syndrome and educate the client about dietary modifications to minimize episodes.

• Encourage the client to eat small, frequent meals with a focus on high-protein and low-carbohydrate foods to slow gastric emptying.
• Advise the client to lie down or recline for 20–30 minutes after meals to reduce the speed of gastric emptying.
• Encourage the client to avoid high-sugar foods and fluids, which can exacerbate symptoms.
• Separate fluid and solid intake, suggesting the client drink fluids 30 minutes to 1 hour before or after meals, but not during meals.
• Document and report severe or recurrent episodes to the healthcare provider for further evaluation and management.

✘Incorrect answer options:

Slow heart rate and indigestion: Slow heart rate (bradycardia) is not associated with dumping syndrome. In contrast, tachycardia (fast heart rate) is a more common finding due to autonomic nervous system activation in response to hypovolemia. Indigestion alone is also not a primary feature of dumping syndrome.

Blurred vision and chest discomfort: While these symptoms may suggest other serious conditions (e.g., cardiac issues or neurological problems), they are not typical of dumping syndrome. Early dumping syndrome primarily causes gastrointestinal and autonomic symptoms.

Abdominal cramping and pain: Although abdominal cramping can occur with dumping syndrome, it is more characteristic of late dumping syndrome, which occurs 1–3 hours after meals due to a rapid rise and fall in blood glucose levels. Early dumping syndrome is more associated with systemic symptoms such as sweating and pallor.

EXPLANATION

✔Correct answer:

It reduces the signals that stimulate acid production. A vagotomy is a surgical procedure that involves cutting branches of the vagus nerve to reduce acid secretion in the stomach. The vagus nerve normally stimulates the release of gastric acid by signaling the stomach to produce digestive juices. In clients with peptic ulcers, excessive acid can erode the stomach lining, delaying healing and increasing the risk of complications such as perforation or bleeding. By reducing the vagus nerve’s stimulation, the procedure decreases acid production, helping to prevent further ulcer formation and promoting healing.

There are several types of vagotomy, such as truncal vagotomy, selective vagotomy, and highly selective vagotomy, with varying degrees of specificity in targeting gastric acid secretion while preserving other vagal functions.

Think of the stomach as a faucet that releases acid to help digest food, and the vagus nerve as the handle that controls the water flow. In peptic ulcer disease, the handle is stuck in the "on" position, causing too much acid to flow and damage the stomach lining. A vagotomy is like turning off the handle so the faucet stops releasing excess acid, allowing the stomach to heal without constant irritation.

Nurse Julia should ensure Mr. Andrews understands the purpose of the procedure, its benefits, and its potential side effects.

• Explain that the vagotomy reduces acid secretion and helps manage peptic ulcers that do not respond to medication or lifestyle changes.
• Reassure the client that this procedure helps prevent complications, such as bleeding or perforation, associated with chronic peptic ulcers.
• Educate the client about possible post-operative effects, such as changes in gastric motility or digestion, and discuss strategies to manage them.
• Monitor for potential complications post-surgery, such as dumping syndrome, which may occur in some types of vagotomy.
• Reinforce adherence to dietary modifications and medication regimens prescribed for ulcer management.

✘Incorrect answer options:

It lowers the stomach's ability to absorb food: Vagotomy does not affect the stomach's ability to absorb nutrients, as the stomach is not the primary site of absorption (this occurs mainly in the small intestine). The procedure is focused on reducing acid production, not altering nutrient absorption.

It promotes healing of the stomach lining: While a vagotomy indirectly promotes healing by reducing acid secretion, this is not the primary explanation for its purpose. It is designed to control the root cause (excessive acid), which helps the stomach lining heal over time.

It stops the body's stress responses: Vagotomy targets the vagus nerve’s influence on gastric acid secretion, not the broader stress response. The stress response involves multiple systems, including the sympathetic nervous system, which is not directly impacted by this procedure.

EXPLANATION

✔Correct answer:

Increase daily fluid intake. To improve the effectiveness of colostomy irrigation and enhance fecal returns, increasing daily fluid intake is essential. Adequate hydration helps soften stool, making it easier for the colostomy to empty during irrigation. Clients with colostomies are at a higher risk for dehydration, as some fluid absorption normally occurring in the colon may be reduced. Maintaining optimal hydration supports regular bowel function and ensures that irrigation procedures are more effective and less uncomfortable.

Encouraging the client to consume sufficient fluids (unless contraindicated due to medical conditions like heart or kidney failure) promotes overall colostomy function and reduces the likelihood of constipation or incomplete fecal returns during irrigation.

Think of the colon as a garden hose. If there isn't enough water flowing through the hose (fluids in the body), it becomes harder to flush out debris (stool). Drinking more fluids helps maintain a steady flow, making the "flushing" process easier during irrigation.

Nurse Linda should provide Ms. Carter with instructions and strategies to ensure effective colostomy irrigation and optimal colostomy management.

• Encourage the client to drink at least 2–3 liters of water daily (if not contraindicated) to promote hydration and soften stools.
• Instruct the client to establish a regular irrigation schedule, preferably after a meal when peristalsis is naturally more active, to enhance fecal returns.
• Teach the client to use lukewarm irrigation solution, as cold solutions can cause cramping and warm solutions may overstimulate peristalsis.
• Educate the client on the importance of a balanced diet, including fiber, to promote healthy bowel movements.
• Provide reassurance and guidance to ensure the client feels confident in managing their colostomy independently.

✘Incorrect answer options:

Schedule the irrigation in the evening: Irrigation is generally more effective when performed at the same time each day, ideally in the morning after breakfast. This takes advantage of the body's natural increase in peristalsis after eating. Evening irrigation is not as effective for most clients and could interfere with sleep.

Use a smaller amount of irrigation solution: Reducing the amount of irrigation solution is not recommended, as an inadequate volume may fail to stimulate sufficient peristalsis or clear stool effectively. Clients should use the prescribed amount, typically 500–1,000 mL of solution, based on their healthcare provider's recommendation.

Apply heat to the abdomen: While applying heat can sometimes help relieve abdominal cramping, it does not directly enhance the effectiveness of colostomy irrigation. Ensuring proper hydration and using the correct irrigation technique are more effective strategies.

EXPLANATION

✔Correct answer:

Administer a lactulose enema as prescribed. The priority intervention for managing hepatic encephalopathy is administering lactulose, either orally or via enema, as prescribed. Lactulose is a non-absorbable sugar that works by reducing serum ammonia levels—a key factor in the development of hepatic encephalopathy. It acidifies the colon, converting ammonia (NH₃) into ammonium (NH₄⁺), which is less absorbable and excreted in the stool. Additionally, lactulose promotes frequent bowel movements to help eliminate ammonia-producing bacteria and toxins from the intestines.

This intervention directly targets the underlying pathophysiology of hepatic encephalopathy, making it the priority action to improve the patient's condition. By lowering ammonia levels, lactulose helps reduce neurological symptoms such as confusion, lethargy, and asterixis.

Think of the body as a house where garbage (ammonia) has built up. Lactulose works like a garbage truck, collecting and removing the waste, so the house can function properly again.

Nurse Rachel should monitor the effectiveness of lactulose and assess for side effects or complications.

• Monitor the frequency and consistency of bowel movements to ensure lactulose is effective (goal: 2–3 soft stools per day).
• Assess serum ammonia levels to evaluate the treatment’s success in reducing neurotoxins.
• Observe for improvements in mental status, such as reduced confusion, improved alertness, or decreased asterixis.
• Educate the patient and family about lactulose’s purpose and its expected side effects, such as diarrhea or abdominal cramping, while reinforcing the importance of adhering to the treatment regimen.
• Monitor for dehydration or electrolyte imbalances caused by diarrhea, and intervene as needed (e.g., fluid replacement or electrolyte supplementation).

✘Incorrect answer options:

Promote a diet high in protein: While protein is important for nutrition, patients with hepatic encephalopathy may need a low-to-moderate protein diet to reduce ammonia production from protein metabolism. High protein intake could exacerbate symptoms, although this should be individualized based on the patient’s condition and nutritional status.

Use sedatives as needed for agitation: Sedatives are generally avoided in hepatic encephalopathy because they can worsen mental status and mask symptoms of neurological decline. The focus should be on treating the underlying cause of agitation, such as high ammonia levels, rather than suppressing symptoms.

Encourage walking four times daily: While activity is important for overall health, prioritizing physical activity during an acute episode of hepatic encephalopathy is not appropriate. The patient may be confused or lethargic, making walking unsafe. Focus should instead be on interventions that address the underlying condition.