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Gastrointestinal Management 5 Let whoever is in charge keep this simple question in her head—NOT how can I always do the right thing myself but how can I provide for this right thing always to be done. —Florence Nightingale QUESTIONS 1. The nurse is caring for clients on a medical unit. Which task should the nurse implement first? 1. Change the abdominal surgical dressing for a client who has ambulated in the hall. 2. Discuss the correct method of placing Montgomery straps on the client with the UAP. 3. Assess the male client who called the desk to say he is nauseated and just vomited. 4. Place a call to the extended care facility to give the report on a discharged client. 2. The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fuid intake after the procedure. 3. Explain to the client that he or she will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure. 3. Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with dyspepsia who has eructation and bloating. 2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia. 3. The client with diverticulitis who has left lower quadrant pain and fever. 4. The client with Crohn’s disease who has right lower abdominal pain and diarrhea. 4. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. 2. Request the UAP change the linens for the 89-year-old client with fecal incontinence. 3. Tell the UAP to assist the 54-year-old client with a bowel management program. 4. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis. 5. Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? 1. The UAP is refusing to feed the client diagnosed with acute diverticulitis. 2. The UAP would not place the client on the bedside commode who was on bed rest. 3. The UAP placed the client with a continuous feeding tube in the supine position. 4. The UAP placed sequential compression devices on the client who is on strict bed rest. 109 110 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 6. The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. Which action is most appropriate for the nurse to implement first? 1. Discuss the blood administration fow sheet with the chief nursing offcer. 2. Contact an individual to help design a new blood transfusion fow sheet. 3. Learn to adapt to the present form and do not take any further action. 4. Volunteer to be on an ad hoc committee to research alternate fow sheets. 7. The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure? 1. The cardiac catheterization department. 2. The dietary department. 3. The nuclear medicine department. 4. The hospital laboratory department. 8. The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received three units of packed red blood cells (RBCs). 2. The client scheduled for an esophagogastroduodenoscopy in the morning. 3. The client with short bowel syndrome who has diarrhea and a K+ level of 3.3 mEq/L. 4. The client who has just returned from surgery for a sigmoid colostomy. 9. At 0830, the day shift nurse is preparing to administer medications to the client NPO for an endoscopy. Which medication should the nurse question administering? Select all that apply. Client’s Name: Account Number: 123456 Allergies: Penicillin Date: Medication 2301–0700 0701–1500 1501–2300 Lanoxin (digoxin) 0900 0.125 mg PO every day Lasix (furosemide) 0900 1600 40 mg PO bid Zantac (ranitidine) 0300 NN@11 mL/hr 150 mg in 250 mL NS IV continuous infusion every 24 hours Vancomycin 0900 2100 850 mg IVPB every 24 hours Mylanta 30 mL PO PRN heart burn. Signature/Initials Day Nurse RN DN Night Nurse RN NN 1. Lanoxin (digoxin) 0.125 mg PO every day. 2. Lasix (furosemide) 40 mg PO bid. 3. Zantac (ranitidine) 150 mg in 250 mL NS IV continuous infusion every 24 hours. 4. Vancomycin 850 mg IVPB every 24 hours. 5. Mylanta 30 mL PO PRN heartburn. CHAPTER 5 GASTROINTESTINAL MANAGEMENT 111 10. Which client should the nurse assess first after receiving the p.m. shift assessment? 1. The client with Barrett’s esophagus who has dysphagia and pyrosis. 2. The client with proctitis who has tenesmus and passage of mucus through the rectum. 3. The client with liver failure who is jaundiced and has ascites. 4. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr. 11. The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? 1. Altered nutrition. 2. Self-care defcit. 3. Impaired body image. 4. Fluid and electrolyte imbalance. QUESTIONS 12. The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first? 1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn’s disease. 2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia. 3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease. 4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery. 13. The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? 1. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants. 2. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset. 3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen. 4. The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10. 14. The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone? 1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm. 2. The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36. 3. The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL. 4. The client who is 8 hours postoperative for exploratory laparotomy who has a serum potassium level of 4.5 mEq/L. 15. The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abdominal mass who is overweight. 2. The client scheduled for a gastrectomy who has arterial hypertension. 3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day. 4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis. 112 PRIORITIZATION, DELEGATION, AND MANAGEMENT OF CARE FOR THE NCLEX-RN® EXAM 16. The nurse is performing ostomy care for a client who had an abdominal-peritoneal resection with a permanent sigmoid colostomy. Rank the following interventions in order of priority. 1. Cleanse the stomal site with mild soap and water. 2. Assess the stoma for a pink, moist appearance. 3. Monitor the drainage in the ostomy drainage bag. 4. Apply stoma adhesive paste to the skin around the stoma. 5. Attach the ostomy drainage bag to the abdomen. 17. The nurse is transcribing the HCP’s orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? 1. Obtain the client’s informed consent. 2. Administer 2 mg of IV morphine, every 4 hours, PRN. 3. Shave the lower right abdominal quadrant. 4. Administer the on-call IVPB antibiotic. 18. The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? 1. Place sterile normal saline gauze on the eviscerated area. 2. Reinforce the abdominal dressing with an ABD pad. 3. Assess the client’s abdominal bowel sounds. 4. Place the client in the left lateral position. 19. The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first? 1. The client who has a paralytic ileus and has absent bowel sounds. 2. The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen. 3. The client who is 6 hours postoperative and has an abdominal wound dehiscence. 4. The client who had a liver transplant and is being transferred to the rehabilitation unit.

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