GI Exam 2

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of:

a. 45 units/L
b. 100 units/L
c. 300 units/L
d. 500 units/L

c. 300 units/L
The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.

Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of:

a. Pork
b. Milk
c. Chicken
d. Broccoli

a. Pork
The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid

Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?

a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D

a. Hepatitis A
Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?

a. Elevated hemoglobin level
b. Elevated serum bilirubin level
c. Elevated blood urea nitrogen level
d. Decreased erythrocycle sedimentation rate

b. Elevated serum bilirubin level
Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.

The nurse is reviewing the physician’s orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client’s chart?

a. NPO status
b. Nasogastric tube inserted
c. Morphine sulfate for pain
d. An anticholinergic medication

c. Morphine sulfate for pain
Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis.

The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?

a. Clamp the T tube
b. Irrigate the T tube
c. Notify the physician
d. Document the findings

d. Document the findings
Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer?

a. Bradycardia
b. Numbness in the legs
c. Nausea and vomiting
d. A rigid, board-like abdomen

d. A rigid, board-like abdomen
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy?

a. Halts stress reactions
b. Heals the gastric mucosa
c. Reduces the stimulus to acid secretions
d. Decreases food absorption in the stomach

c. Reduces the stimulus to acid secretions
A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy.

When evaluating a male client for complications of acute pancreatitis, the nurse would observe for:

a. increased intracranial pressure.
b. decreased urine output.
c. bradycardia.
d. hypertension.

b. decreased urine output.
Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn’t related to acute pancreatitis.

The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

a. Dyspnea and fatigue
b. Ascites and orthopnea
c. Purpura and petechiae
d. Gynecomastia and testicular atrophy

c. Purpura and petechiae
A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

a. Appendicitis
b. Pancreatitis
c. Cholecystitis
d. Gastric ulcer

b. Pancreatitis
Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other conditions are less likely to exhibit fluid volume deficit.

A male client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because:

a. meperidine provides a better, more prolonged analgesic effect.
b. morphine may cause spasms of Oddi’s sphincter.
c. meperidine is less addictive than morphine.
d. morphine may cause hepatic dysfunction.

b. morphine may cause spasms of Oddi’s sphincter.
For a client with pancreatitis, the physician will probably avoid prescribing morphine because this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct), causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than morphine. The two drugs are equally addictive. Morphine isn’t associated with hepatic dysfunction.

Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

a. Endoscopy
b. Upper GI series
c. Hemoglobin (Hb) levels and hematocrit (HCT)
d. Arteriography

a. Endoscopy
Endoscopy permits direct evaluation of the upper GI tract and can detect 90% of bleeding lesions. An upper GI series, or barium study, usually isn’t the diagnostic method of choice, especially in a client with acute active bleeding who’s vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn’t necessarily reveal whether the lesion is bleeding. Hb levels and HCT, which indicate loss of blood volume, aren’t always reliable indicators of GI bleeding because a decrease in these values may not be seen for several hours. Arteriography is an invasive study associated with life-threatening complications and wouldn’t be used for an initial evaluation.

A female client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response?

a. “You may have eaten contaminated restaurant food.”
b. “You could have gotten it by using I.V. drugs.”
c. “You must have received an infected blood transfusion.”
d. “You probably got it by engaging in unprotected sex.”

a. “You may have eaten contaminated restaurant food.”
Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn’t transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

A female client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:

a. whole blood and albumin.
b. platelets and packed red blood cells.
c. fresh frozen plasma and whole blood.
d. cryoprecipitate and fresh frozen plasma.

d. cryoprecipitate and fresh frozen plasma.
The liver is vital in the synthesis of clotting factors, so when it’s diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren’t specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.

What laboratory finding is the primary diagnostic indicator for pancreatitis?

a. Elevated blood urea nitrogen (BUN)
b. Elevated serum lipase
c. Elevated aspartate aminotransferase (AST)
d. Increased lactate dehydrogenase (LD)

b. Elevated serum lipase
Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client’s BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

a. yellow sclerae.
b. light amber urine.
c. circumoral pallor.
d. black, tarry stools.

a. yellow sclerae.
Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don’t occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

a. a sedentary lifestyle and smoking.
b. a history of hemorrhoids and smoking.
c. alcohol abuse and a history of acute renal failure.
d. alcohol abuse and smoking.

d. alcohol abuse and smoking.
Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren’t risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

a. Regular diet
b. Skim milk
c. Nothing by mouth
d. Clear liquids

c. Nothing by mouth
Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn’t be given because it increases gastric acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled.

A male client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

a. severe abdominal pain radiating to the shoulder.
b. anorexia, nausea, and vomiting.
c. eructation and constipation.
d. abdominal ascites.

b. anorexia, nausea, and vomiting.
Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn’t radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

A female client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

a. place the client in a private room.
b. wear a mask when handling the client’s bedpan.
c. wash the hands after touching the client.
d. wear a gown when providing personal care for the client.

c. wash the hands after touching the client.
To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

Which of the following factors can cause hepatitis A?

a. Contact with infected blood
b. Blood transfusions with infected blood
c. Eating contaminated shellfish
d. Sexual contact with an infected person

c. Eating contaminated shellfish
Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

Which of these agents is a major contributing factor in the promotion of peptic ulcer disorder?

a. Candida albicans
b. Staphylococcus infection
c. Streptococcus infection
d. Helicobacter pylori infection

d. Helicobacter pylori infection
Recurrence of peptic ulcers is related to Helicobacter pylori, use of NSAIDs, smoking, and continued acid hypersecretion.
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
1. The client awaiting hiatal hernia repair at 11 am.
2. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
3. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain.
4. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
3, 4, 2, 1
The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client’s pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
1. An intestinal obstruction has developed.
2. Additional ulcers have developed.
3. The esophagus has become inflamed.
4. The ulcer has perforated.
4. The ulcer has perforated.
The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. An intestinal obstruction would not cause midepigastric pain. The development of additional ulcers or esophageal inflammation would not cause a rigid, boardlike abdomen.
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply.
1. Epigastric pain at night.
2. Relief of epigastric pain after eating.
3. Vomiting.
4. Weight loss.
5. Melena.
3. Vomiting.
4. Weight loss.
5. Melena.
Vomiting and weight loss are common with gastric ulcers. The client may also have blood in the stools (melena) from gastric bleeding. Clients with a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about 1 hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are more likely to complain about pain that occurs during the night and is frequently relieved by eating.
A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?
1. Ineffective coping related to fear of diagnosis of chronic illness.
2. Deficient knowledge related to unfamiliarity with significant signs and symptoms.
3. Constipation related to decreased gastric motility.
4. Imbalanced nutrition: Less than body requirements related to gastric bleeding.
2. Deficient knowledge related to unfamiliarity with significant signs and symptoms.
Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stool causes it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider. The data do not support the other diagnoses.
A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug?
1. Heal the ulcer.
2. Protect the ulcer surface from acids.
3. Reduce acid concentration.
4. Limit gastric acid secretion.
4. Limit gastric acid secretion.
Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretory, or proton-pump inhibitors, such as omeprazole (Prilosec), help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate (Carafate), protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.
A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply.
1. Obtain adequate rest to reduce stimulation.
2. Eat small, frequent meals throughout the day.
3. Take all medications on time as ordered.
4. Sit up for one hour when awakened at night.
5. Stay away from crowded areas.
1. Obtain adequate rest to reduce stimulation.
2. Eat small, frequent meals throughout the day.
3. Take all medications on time as ordered.
4. Sit up for one hour when awakened at night.
The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.
A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply.
1. Administering an antacid hourly until nausea subsides.
2. Monitoring the client’s vital signs.
3. Notifying the physician of the client’s symptoms.
4. Initiating oxygen therapy.
5. Reassessing the client in an hour.
2. Monitoring the client’s vital signs.
3. Notifying the physician of the client’s symptoms.
The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client’s vital signs and notify the physician of the client’s symptoms. To administer an antacid hourly or to wait 1 hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.
The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following?
1. Bland foods.
2. High-protein foods.
3. Any foods that are tolerated.
4. Large amounts of milk.
3. Any foods that are tolerated.
Diet therapy for ulcer disease is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate. There is no need for the client to ingest only a bland or high-protein diet. Milk may be included in the diet, but it is not recommended in excessive amounts.
The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse’s response to observing these actions should be based on knowledge that:
1. Involvement with his job will keep the client from becoming bored.
2. A relaxed environment will promote ulcer healing.
3. Not keeping up with his job will increase the client’s stress level.
4. Setting limits on the client’s behavior is an important nursing responsibility.
2. A relaxed environment will promote ulcer healing.
A relaxed environment is an essential component of ulcer healing. Nurses can help clients understand the importance of relaxation and explore with them ways to balance work and family demands to promote healing. Being involved with his work may prevent boredom; however, this client is upset and argumentative. Not keeping up with his job will probably increase the client’s stress level, but the nurse’s response is best if it is based on the fact that a relaxed environment is an essential component of ulcer healing. Nurses cannot set limits on a client’s behavior; clients must make the decision to make lifestyle changes.
A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan?
1. Conduct physical activity in the morning so that he can rest in the afternoon.
2. Have the family agree to perform the necessary yard work at home.
3. Give up jogging and substitute a less demanding hobby.
4. Incorporate periods of physical and mental rest in his daily schedule.
4. Incorporate periods of physical and mental rest in his daily schedule.
It would be most effective for the client to develop a health maintenance plan that incorporates regular periods of physical and mental rest in the daily schedule. Strategies should be identified to deal with the types of physical and mental stressors that the client needs to cope with in the home and work environments. Scheduling physical activity to occur only in the morning would not be restful or practical. There is no need for the client to avoid yard work or jogging if these activities are not stressful.
A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?
1. Before meals.
2. With meals.
3. At bedtime.
4. When pain occurs.
3. At bedtime.
Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime. It is not necessary to take the drug before meals. The client should take the drug regularly, not just when pain occurs.
A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?
1. The client has not been including enough fiber in his diet.
2. The client needs to increase his daily exercise.
3. The client is experiencing an adverse effect of the aluminum hydroxide.
4. The client has developed a gastrointestinal obstruction.
3. The client is experiencing an adverse effect of the aluminum hydroxide.
It is most likely that the client is experiencing an adverse effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve the constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of a bowel obstruction.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
1. “I should take my antacid before I take my other medications.”
2. “I need to decrease my intake of fluids so that I don’t dilute the effects of my antacid.”
3. “My antacid will be most effective if I take it whenever I experience stomach pains.”
4. “It is best for me to take my antacid 1 to 3 hours after meals.”
4. “It is best for me to take my antacid 1 to 3 hours after meals.”
Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.
Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will:
1. Demonstrate appropriate use of analgesics to control pain.
2. Explain the rationale for eliminating alcohol from the diet.
3. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
4. Eliminate contact sports from his or her lifestyle.
2. Explain the rationale for eliminating alcohol from the diet.
Alcohol is a gastric irritant that should be eliminated from the intake of the client with peptic ulcer disease. Analgesics are not used to control ulcer pain; many analgesics are gastric irritants. The client’s hemoglobin and hematocrit typically do not need to be monitored every 3 months, unless gastrointestinal bleeding is suspected. The client can maintain an active lifestyle and does not need to eliminate contact sports as long as they are not stress-inducing.

A client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

a. Esophageal varices
b. Ascites
c. Peripheral edema
d. Asterixis (liver flap)

a. Esophageal varices
When a client has esophageal varices, the vessels become very fragile and massive hemorrhage can occur. The mortality rate is 30% – 50% after an episode of bleeding. Ascites and edema occur when liver production of albumin fails. Asterixis is a sign of hepatic encephalopathy.

In caring for a client with acute viral hepatitis, which task should be delegated to the nursing assistant?

a. Empty the bedpan while wearing gloves.
b. Suggest diversional activities.
c. Monitor dietary preferences.
d. Reports signs and symptoms of jaundice.

a. Empty the bedpan while wearing gloves.
The nursing assistant should use infection control precautions for the protection of self, employees, and other clients. Planning and monitoring are RN responsibilities. While the nursing assistants can report valuable information, they should not be responsible for signs and symptoms that can be subtle or hard to detect, such as skin changes.

You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious?

a. Projectile vomiting
b. Burning sensation 2 hours after eating
c. Coffee-grounded emesis
d. Board-like abdomen with shoulder pain

d. Board-like abdomen with shoulder pain
A board-like abdomen with shoulder pain is a symptom of a perforation, which is most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint, which can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding and will require diagnostic testing.

The nurse knows that serum amylase levels return to normal within which timeframe?

a. 48 hours
b. 36 hours
c. 12 hours
d. 24 hours

a. 48 hours
Serum amylase usually returns to normal within 48 – 72 hours.

Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

a. Polyuria
b. Warm moist skin
c. Bradycardia
d. Hypotension

d. Hypotension
Signs of potential hypovolemia include cool, clammy skin, tachycarida, decreased blood pressure, and decreased urine output.

Which of the following would be the least important assessment in a patient diagnosed with ascites?

a. Measurement of abdominal girth
b. Foul-smelling breath
c. Weight
d. Palpation of the abdomen for a fluid shift

b. Foul-smelling breath
Foul-smelling breath would not be considered an important assessment for this patient. Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the patient diagnosed with ascites.

Which enzyme aids in the digestion of protein?

a. Amylase
b. Lipase
c. Pepsin
d. Trypsin

d. Trypsin
Trypsin is an enzyme that aids in the digestion of protein. Lipase is an enzyme that aids in the digestion of fats. Pepsin is a gastric enzyme that aids in the digestion of fats. Amylase is an enzyme that aids in the digestion of starch.

Which of the following may be a potential cause of hypoglycemia in the patient diagnosed with diabetes mellitus.

a. The patient has not been exercising.
b. The patient has not been compliant with the prescribed treatment regimen.
c. The patient has not consumed food and continues to take insulin or oral antidiabetic medications.
d. The patient has consumed food and has not taken or received insulin.

c. The patient has not consumed food and continues to take insulin or oral antidiabetic medications.
Hypoglycemia occurs when a patient with diabetes is not eating at all and continues to take insulin or oral antidiabetic medications. Hypoglycemia does not occur when the patient has not been compliant with the prescribed treatment regimen. If the patient has eaten and has not taken or received insulin, DKA is more likely to develop.

Which of the following terms describes the passage of a hollow instrument into a cavity for the withdrawal of fluid?

a. Dialysis
b. Paracentesis
c. Ascites
d. Asterixis

b. Paracentesis
Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Asterixis refers to involuntary flapping movements of the the hands associated with metabolic liver dysfunction. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.

Which type of jaundice is the result of increased destruction of red blood cells?

a. Hemolytic
b. Obstructive
c. Nonobstructive
d. Hepatocellular

a. Hemolytic
Hemolytic jaundice is the result of an increased destruction of the red blood cells. Hepatocellular jaundice is caused by the inability of the damaged liver cells to clear normal amounts of bilirubin from the blood. Obstructive jaundice resulting from extrahepatic obstruction may be caused by occlusion of the bile duct from a gall stone, inflammatory process, a tumor, or pressure from an enlarged organ. Nonobstructive jaundice occurs with hepatitis.

Which of the following is clinical manifestation of cholelithiasis?

a. Upper left quadrant abdominal pain
b. Epigastric distress prior to a meal
c. Clay-colored stools
d. Nonpalpable abdominal mass

c. Clay-colored stools
The patient with gallstones has clay-colored stools, and excruciating upper right quadrant pain that radiates to the back or right shoulder. The patient develops a fever and may have a palpable abdominal mass.

Which of the following neuroregulators increase gastric acid secretion?

a. Acetylcholine
b. Norepinephrine
c. Secretin
d. Gastrin

a. Acetylcholine
Acetylcholine causes increased gastric acid. Norepinephrine inhibits secretions of the GI tract. Gastrin increases secretion of gastric juice, which is rich in HCl. Secretin in the stomach inhibits gastric secretion somewhat.

Which of the following categories or oral antidiabetic agents exert their primary action by directly stimulating the pancreas to secrete insulin?

a. Alpha glucosidase inhibitors
b. Sulfonylureas
c. Biguanides
d. Thiazolidinediones

b. Sulfonylureas
A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate insulin’s action on peripheral receptor sites. Alpha glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

Which of the following would be inconsistent as a cause of DKA?

a. Decreased or missed dose of insulin
b. Illness of infection
c. Competency in injecting insulin
d. Undiagnosed and untreated diabetes

c. Competency in injecting insulin

Which dietary modification is utilized for a patient diagnosed with acute pancreatitis?

a. High-fat diet
b. Elimination of coffee
c. High-protein diet
d. Low-carbohydrate diet

b. Elimination of coffee
A high-carbohydrate, low-fat, and low-protein diet should be implemented.

Which of the following is the major cause of morbidity and mortality in patients with chronic pancreatitis?

a. Tetany
b. Pancreatic necrosis
c. MODS
d. Shock

b. Pancreatic necrosis
Pancreatic necrosis is a major cause of morbidity and mortality in patient with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause or morbidity and mortality in patients with chronic pancreatitis.

Which of the following are byproducts of fat breakdown, which accumulate in the blood and urine?

a. Creatinine
b. Hemoglobin
c. Ketones
d. Cholesterol

c. Ketones
Ketones are byproducts of fat breakdown, and they accumulate in the blood and urine. Creatinine, hemoglobin, and cholesterol are not byproducts of fat breakdown.

Which of the following medications are used to decrease portal pressure, halting bleeding or esophageal varices?

a. Sprironaclactone (Aldactone)
b. Nitroglycerin
c. Cimetidine (Tagamet)
d. Vasopressin (Pitressin)

d. Vasopressin (Pitressin)
Vasopressin may be the intitial therapy for esophageal varices, because it produces constriction of the sphlanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to precvent the side effects of Vasopressin. Aldactone and Tagamet do not decrease portal hypertension.
Gastric ulcer
ulceration of the mucosal lining that extends to the submucosal layer of the stomach
Predisposing factors for gastric ulcer
stress
smoking
the use of corticosteroids, NSAIDs, and alcohol
hx of gastritis
family hx of gastric ulcers
infection with H. Pylori
Complications of gastric ulcers
hemorrhage
perforation
pyloric obstruction
Signs and symptoms of gastric ulcers
Gnawing sharp pain in or left of the midepigastric region 30 – 60 minutes after a meal
food ingestion accentuates pain
hematemesis
Signs and symptoms of duodenal ulcers
Burning pain midepigastric area 1.5 – 3 hours after a meal and during the night
melena
pain is relieved by ingestion of food
Nursing interventions for gastric ulcers
Monitor vital signs and for signs of bleeding.
Administer small, frequent bland feedings during the active phase.
Administer H2-receptor antagonists or proton pump inhibitors as prescribed to decrease the secretion of gastric acid.
Administer antacids as prescribed to neutralize gastric secretions.
Administer anticholinergics as prescribed to reduce gastric motility.
Administer mucosal barrier protectants as prescribed 1 hour before each meal.
Administer prostaglandins as prescribed for their protective and antisecretory actions.

The nurse administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7 a.m. At what time would the nurse expect the client to be most at risk for a hypoglycemic reaction?

1. 10 a.m.
2. Noon
3. 4 p.m.
4. 10 p.m.

3. 4 p.m.
NPH is an intermediate-acting insulin that peaks 8 to 12 hours after administration. Because the nurse administered NPH insulin at 7 a.m., the client is at greatest risk for hypoglycemia from 3 to 7 p.m.

A client with pancreatitis complains of pain. The nurse expects the physician to prescribe meperidine (Demerol) instead of morphine to relieve pain because:

1. meperidine provides a better, more prolonged analgesic effect.
2. morphine may cause spasms of Oddi’s sphincter.
3. meperidine is less addictive than morphine.
4. morphine may cause hepatic dysfunction.

2. morphine may cause spasms of Oddi’s sphincter.
For a client with pancreatitis, the physician will probably avoid prescribing morphine because this drug may trigger spasms of the sphincter of Oddi (a sphincter at the end of the pancreatic duct), causing irritation of the pancreas. Meperidine has a somewhat shorter duration of action than morphine. The two drugs are equally addictive. Morphine isn’t associated with hepatic dysfunction.

A client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse would be most accurate in stating:

1. “The test needs to be repeated following a 12-hour fast.”
2. “It looks like you aren’t following the prescribed diabetic diet.”
3. “It tells us about your sugar control for the last 3 months.”
4. “Your insulin regimen needs to be altered significantly.”

3. “It tells us about your sugar control for the last 3 months.”
The glycosylated Hb test provides an objective measure of glycemic control over a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesn’t require a fasting period before blood is drawn. The nurse can’t conclude that the result occurs from poor dietary management or inadequate insulin coverage.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client’s behavior is:

1. elevated liver enzymes and low serum protein level.
2. subnormal serum glucose and elevated serum ammonia levels.
3. subnormal clotting factors and platelet count.
4. elevated blood urea nitrogen and creatinine levels and hyperglycemia.

2. subnormal serum glucose and elevated serum ammonia levels.
In acute liver failure, serum ammonia levels increase because the liver can’t adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn’t capable of releasing stored glucose. Both elevated serum ammonia and subnormal serum glucose levels depress the level of a client’s consciousness. The other diagnostic values aren’t as directly related to the client’s level of consciousness.

Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a client with type 2 diabetes mellitus. During discharge planning, the nurse would be aware of the client’s need for additional teaching when the client states:

1. “If I have hypoglycemia, I should eat some sugar, not dextrose.”
2. “The drug makes my pancreas release more insulin.”
3. “I should never take insulin while I’m taking this drug.”
4. “It’s best if I take the drug with the first bite of a meal.”

1. “If I have hypoglycemia, I should eat some sugar, not dextrose.”
Acarbose delays glucose absorption, so the client should take an oral form of dextrose rather than a product containing table sugar when treating hypoglycemia. The alpha-glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. It’s safe to be on a regimen that includes insulin and an alpha-glucosidase inhibitor. The client should take the drug at the start of a meal, not 30 minutes to an hour before.

The nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission?

1. Regular diet
2. Skim milk
3. Nothing by mouth
4. Clear liquids

3. Nothing by mouth
Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. A regular diet is incorrect. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn’t be given because it increases gastric acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled.

When caring for a client with a history of hypoglycemia, the nurse should avoid administering a drug that may potentiate hypoglycemia. Which drug fits this description?

1. sulfisoxazole (Gantrisin)
2. mexiletine (Mexitil)
3. prednisone (Orasone)
4. lithium carbonate (Lithobid)

1. sulfisoxazole (Gantrisin)
Sulfisoxazole and other sulfonamides are chemically related to oral antidiabetic agents and may precipitate hypoglycemia. Mexiletine, an antiarrhythmic, is used to treat refractory ventricular arrhythmias; it doesn’t cause hypoglycemia. Prednisone, a corticosteroid, is associated with hyperglycemia. Lithium may cause transient hyperglycemia, not hypoglycemia.

The nursing staff has just been trained how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

1. Ungloving the hands when removing the test strip
2. Smearing the drop of blood onto the reagent pad
3. Calibrating the machine after installing a new battery
4. Starting the timer on the machine while gathering supplies

3. Calibrating the machine after installing a new battery
To obtain accurate readings, the nurse should calibrate the machine whenever a new battery is installed. To adhere to standard precautions and prevent contact with blood, the nurse’s hands should remain gloved throughout blood glucose testing. The nurse should drop the blood — not smear it — on the reagent pad because smearing can cause an inaccurate reading. To help ensure accurate results, the nurse shouldn’t start the timer before the blood sample is collected.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

1. Dyspnea and fatigue
2. Ascites and orthopnea
3. Purpura and petechiae
4. Gynecomastia and testicular atrophy

3. Purpura and petechiae
A hepatic disorder, such as cirrhosis, may disrupt the liver’s normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

1. Fatigue
2. Excess fluid volume
3. Ineffective breathing pattern
4. Imbalanced nutrition: Less than body requirements

3. Ineffective breathing pattern
In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

Which factor can cause hepatitis A?

1. Contact with infected blood
2. Blood transfusions with infected blood
3. Eating contaminated shellfish
4. Sexual contact with an infected person

3. Eating contaminated shellfish
Hepatitis A can be caused by consuming contaminated water, milk, or food — especially shellfish from contaminated water. Hepatitis B is caused by blood and sexual contact with an infected person. Hepatitis C is usually caused by contact with infected blood, including receiving blood transfusions.

After a 3-month trial of dietary therapy, a client with type 2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide:

1. 30 minutes before breakfast.
2. in the midmorning.
3. 30 minutes after dinner.
4. at bedtime.

1. 30 minutes before breakfast.
Like other oral antidiabetic agents prescribed in a single daily dose, glyburide should be taken with breakfast or 30 minutes before breakfast. If the client takes glyburide later, such as in the midmorning, after dinner, or at bedtime, the drug won’t provide adequate coverage for all meals consumed during the day.

The nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

1. Cheyne-Stokes respirations
2. Increased urine output
3. Decreased appetite
4. Diaphoresis

2. Increased urine output
Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client’s rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease?

1. To keep gastric pH at 3.0 to 3.5
2. To promote client compliance
3. To maintain a regular bowel pattern
4. To increase pepsin activity

1. To keep gastric pH at 3.0 to 3.5
To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance. Antacids don’t regulate bowel patterns, and they decrease pepsin activity.

While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions?

1. Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospha-Soda.
2. Tell the client he shouldn’t eat or drink for 6 to 12 hours before the procedure.
3. Tell the client he must be on a clear liquid diet for 24 hours before the procedure.
4. Inform the client that he’ll receive a sedative before the procedure.
5. Tell the client that he may eat and drink immediately after the procedure.

2. Tell the client he shouldn’t eat or drink for 6 to 12 hours before the procedure.
4. Inform the client that he’ll receive a sedative before the procedure.
The client shouldn’t eat or drink for 6 to 12 hours before the procedure to assure that his upper GI tract is clear for viewing. The client will receive a sedative before the endoscope is inserted that will help him relax, but allow him to remain conscious. GI tract cleansing and a clear liquid diet are interventions for a client having a lower GI tract procedure, such as a colonoscopy. Food and fluids must be withheld until the gag reflex returns.

The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

1. “Maintain a high-fat diet and drink at least 3 L of fluid a day.”
2. “Maintain a high-sodium, high-calorie diet.”
3. “Maintain a high-carbohydrate, low-fat diet.”
4. “Maintain a high-fat, high-carbohydrate diet.”

3. “Maintain a high-carbohydrate, low-fat diet.”
A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn’t necessary because chronic pancreatitis isn’t associated with hyponatremia or fluid loss.

A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8° F (38.2° C). What effect may this have on his need for insulin?

1. It will have no effect.
2. It will decrease the need for insulin.
3. It will increase the need for insulin.
4. It will cause wide fluctuations in the need for insulin.

3. It will increase the need for insulin.
Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?

1. “Continue to take antacids even if your symptoms subside.”
2. “You may take antacids with other medications.”
3. “Avoid taking magnesium-containing antacids if you develop a heart problem.”
4. “Be sure to take antacids with meals.”

1. “Continue to take antacids even if your symptoms subside.”
Antacids decrease gastric acidity and should be continued even if the client’s symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals.

The nurse must provide total parenteral nutrition (TPN) to a client through a triple-lumen central line. To prevent complications of TPN, the nurse should:

1. cover the catheter insertion site with an occlusive dressing.
2. use clean technique when changing the dressing.
3. insert an indwelling urinary catheter.
4. keep the client on complete bed rest.

1. cover the catheter insertion site with an occlusive dressing.
TPN increases the client’s risk of infection because the catheter insertion site creates a port of entry for bacteria. To reduce the risk of infection, the nurse should cover the insertion site with an occlusive dressing, which is airtight. Because the insertion site is an open wound, the nurse should use sterile technique when changing the dressing. TPN doesn’t necessitate placement of an indwelling urinary catheter or bed rest.

The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:

1. use commercial preparations to remove corns.
2. cut the toenails by rounding edges.
3. wash and inspect the feet daily.
4. walk barefoot at least once each day.

3. wash and inspect the feet daily.
A client with diabetes mellitus should wash and inspect his feet daily and should wear nonconstrictive shoes. Corns should be treated by a podiatrist — not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot.

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

1. severe abdominal pain radiating to the shoulder.
2. anorexia, nausea, and vomiting.
3. eructation and constipation.
4. abdominal ascites.

2. anorexia, nausea, and vomiting.
Hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn’t radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

1. Endoscopy
2. Upper GI series
3. Hemoglobin (Hb) levels and hematocrit (HCT)
4. Arteriography

3. Hemoglobin (Hb) levels and hematocrit (HCT)
Hemoglobin and hematocrit are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding. An upper GI series, or barium study, usually isn’t the diagnostic method of choice, especially in a client with acute active bleeding who’s vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn’t necessarily reveal whether the lesion is bleeding. Arteriography is an invasive study associated with life-threatening complications and wouldn’t be used for an initial evaluation.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

1. Administering an analgesic once per shift, as prescribed, to prevent drug addiction
2. Positioning the client on the side with the knees flexed
3. Encouraging frequent visits from family and friends
4. Administering frequent oral feedings

2. Positioning the client on the side with the knees flexed
The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and prescribed, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and famotidine (Pepcid). Before the client is discharged, the nurse should provide which instruction?

1. “Eat three balanced meals every day.”
2. “Stop taking the drugs when your symptoms subside.”
3. “Avoid aspirin and products that contain aspirin.”
4. “Increase your intake of fluids containing caffeine.”

3. “Avoid aspirin and products that contain aspirin.”
Aspirin is a gastric irritant and should be avoided by clients with peptic ulcer to prevent further erosion of the stomach lining. The client should eat small, frequent meals rather than three large ones. Antacids and ranitidine prevent acid accumulation in the stomach; they should be taken even after symptoms subside. Caffeine should be avoided because it increases acid production in the stomach.

Which disorder is characterized by a sudden drop in blood glucose, followed by rebound hyperglycemia caused by the gradual and excessive administration of insulin?

1. Diabetes insipidus
2. Diabetic ketoacidosis
3. Somogyi phenomenon
4. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

3. Somogyi phenomenon
The Somogyi phenomenon is characterized by a sudden fall in blood glucose, followed by rebound hyperglycemia caused by gradual, excessive administration of insulin. Diabetes insipidus isn’t associated with insulin administration. Diabetic ketoacidosis and HHNS aren’t characterized by this phenomenon.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

1. Appendicitis
2. Pancreatitis
3. Cholecystitis
4. Gastric ulcer

2. Pancreatitis
Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. The other conditions are less likely to exhibit fluid volume deficit.

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide (Tolinase). Which of the following is the most important laboratory test for confirming this disorder?

1. Serum potassium level
2. Serum sodium level
3. Arterial blood gas (ABG) values
4. Serum osmolarity

4. Serum osmolarity
Serum osmolarity is the most important test for confirming HHNS; it’s also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren’t as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable.

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?

1. Withholding all oral intake, as ordered, to decrease pancreatic secretions
2. Administering morphine, as prescribed, to relieve severe pain
3. Limiting I.V. fluids, as ordered, to decrease cardiac workload
4. Keeping the client supine to increase comfort

1. Withholding all oral intake, as ordered, to decrease pancreatic secretions
The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it’s treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

One year ago, a client was diagnosed with cirrhosis of the liver caused by alcohol abuse. Since then, he has been noncompliant with the prescribed protein-restricted diet. After a friend finds him semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he’s diagnosed with hepatic encephalopathy. The physician prescribes lactulose (Cephulac), 200 g diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition is lactulose prescribed?

1. Hyperkalemia
2. Lactic acidosis
3. Hypoglycemia
4. Constipation

4. Constipation
Lactulose also may be used to treat constipation because it produces osmotic diarrhea. It isn’t therapeutic in the treatment of hyperkalemia, lactic acidosis, or hypoglycemia.

Which of the following signs and symptoms would be seen in a client experiencing hypoglycemia?

1. Polyuria, headache, and fatigue
2. Polyphagia and flushed, dry skin
3. Polydipsia, pallor, and irritability
4. Nervousness, diaphoresis, and confusion

4. Nervousness, diaphoresis, and confusion
Signs and symptoms associated with hypoglycemia include nervousness, diaphoresis, weakness, light-headedness, confusion, paresthesia, irritability, headache, hunger, tachycardia, and changes in speech, hearing, or vision. If untreated, signs and symptoms may progress to unconsciousness, seizures, coma, and death. Polydipsia, polyuria, and polyphagia are symptoms associated with hyperglycemia.

A nurse administers glucagon to her diabetic client, then monitors the client for adverse drug reactions and interactions. Which type of drug interacts adversely with glucagon?

1. Oral anticoagulants
2. Anabolic steroids
3. Beta-adrenergic blockers
4. Thiazide diuretics

1. Oral anticoagulants
As a normal body protein, glucagon only interacts adversely with oral anticoagulants, increasing the anticoagulant effects. It doesn’t interact adversely with anabolic steroids, beta-adrenergic blockers, or thiazide diuretics.

What does a positive Chvostek’s sign indicate?

1. Hypocalcemia
2. Hyponatremia
3. Hypokalemia
4. Hypermagnesemia

1. Hypocalcemia
Chvostek’s sign is elicited by tapping the client’s face lightly over the facial nerve, just below the temple. If the client’s facial muscles twitch, it indicates hypocalcemia. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.

A client with peptic ulcer disease is prescribed aluminum-magnesium complex (Riopan). When teaching about this antacid preparation, the nurse should instruct the client to take it with:

1. fruit juice.
2. water.
3. a food rich in vitamin C.
4. a food rich in vitamin D.

2. water.
Water helps transport an antacid to the stomach. The client shouldn’t take an antacid with fruit juice or a food rich in vitamin C or D because the antacid may impair absorption of important nutrients in the juice or food.

The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

1. increasing saturated fat intake and fasting in the afternoon.
2. increasing intake of vitamins B and D and taking iron supplements.
3. eating a candy bar if light-headedness occurs.
4. consuming a low-carbohydrate, high-protein diet and avoiding fasting.

4. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn’t help control hypoglycemia.

Which of the following is an adverse reaction to glipizide (Glucotrol)?

1. Headache
2. Constipation
3. Hypotension
4. Photosensitivity

4. Photosensitivity
Glipizide may cause adverse skin reactions, such as rash, pruritus, and photosensitivity. It doesn’t cause headache, constipation, or hypotension.

A 46-year-old client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client’s blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

1. Sweating, tremors, and tachycardia
2. Dry skin, bradycardia, and somnolence
3. Bradycardia, thirst, and anxiety
4. Polyuria, polydipsia, and polyphagia

1. Sweating, tremors, and tachycardia
Sweating, tremors, and tachycardia are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. In option 3, thirst and anxiety are signs of hypoglycemia, but not bradycardia. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

The nurse is teaching the client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site?

1. Change the needle every 3 days.
2. Wear sterile gloves when inserting the needle.
3. Take the prescribed antibiotics before initiating treatment.
4. Use clean technique when changing the needle.

1. Change the needle every 3 days.
The nurse should teach the client to change the needle every 3 days to prevent infection. The client doesn’t need to wear gloves when changing the needle. Antibiotic therapy isn’t necessary before the initiation of treatment. Sterile technique, not clean technique, is needed when changing the needle.

A 55-year-old diabetic client is admitted with hypoglycemia. Which information should the nurse include in her client teaching?

1. “Hypoglycemia can result from excessive alcohol consumption.”
2. “Skipping meals can cause hypoglycemia.”
3. “Symptoms of hypoglycemia include thirst and excessive urinary output.”
4. “Strenuous activity may result in hypoglycemia.”
5. “Symptoms of hypoglycemia include shakiness, confusion, and headache.”
6. “Hypoglycemia is a relatively harmless situation.”

1. “Hypoglycemia can result from excessive alcohol consumption.”
2. “Skipping meals can cause hypoglycemia.”
4. “Strenuous activity may result in hypoglycemia.”
5. “Symptoms of hypoglycemia include shakiness, confusion, and headache.”
Alcohol consumption, missed meals, and strenuous activity may lead to hypoglycemia. Symptoms of hypoglycemia include shakiness, confusion, headache, sweating, and tingling sensations around the mouth. Thirst and excessive urination are symptoms of hyperglycemia. Hypoglycemia can become a life-threatening disorder involving seizures and death to brain cells; the client shouldn’t be told that the condition is relatively harmless.

A client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

1. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
2. 21 U regular insulin and 9 U NPH.
3. 10 U regular insulin and 20 U NPH.
4. 20 U regular insulin and 10 U NPH.

1. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).
A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 U of NPH and 9 U of regular insulin. The other choices are incorrect dosages for the prescribed insulin.

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician prescribes cimetidine (Tagamet) I.V. The nurse must avoid administering this drug too rapidly because doing so may cause:

1. tetany.
2. bronchospasms.
3. hallucinations.
4. bradycardia.

4. bradycardia.
When given by rapid I.V. injection, cimetidine may cause profound bradycardia and other cardiotoxic effects. Tetany and bronchospasms aren’t associated with cimetidine. Although the drug may cause hallucinations, this adverse reaction doesn’t result simply from rapid administration.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

1. Cool, clammy skin
2. Distended neck veins
3. Increased urine osmolarity
4. Decreased serum sodium level

3. Increased urine osmolarity
In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

The nurse is teaching the client about glipizide (Glucotrol) therapy. The nurse warns the client that glipizide commonly causes hypoglycemia when combined with which over-the-counter preparation?

1. acetaminophen (Tylenol)
2. aspirin
3. St. Johns Wort
4. multivitamins

2. aspirin
When taken in combination with aspirin, glipizide commonly causes hypoglycemia. Acetaminophen, St. John’s Wort, and multivitamins may be taken with glipizide without increasing the risk of hypoglycemia.

A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:

1. urine glucose level.
2. fasting blood glucose level.
3. serum fructosamine level.
4. glycosylated hemoglobin level.

4. glycosylated hemoglobin level.
Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels only give information about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. The nurse should expect the dose’s:

1. onset to be at 2 p.m. and its peak to be at 3 p.m.
2. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
3. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
4. onset to be at 4 p.m. and its peak to be at 6 p.m.

3. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 to 2:30 p.m. and the peak from 4 to 6 p.m.

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. If the physician’s suspicion is correct, the urine will abnormally contain:

1. creatinine.
2. urobilinogen.
3. chloride.
4. albumin.

4. albumin.
Albumin is an abnormal finding in a routine urine specimen. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.

A client is in the late stage of cirrhosis. When planning the client’s diet, the nurse should focus on providing increased amounts of:

1. fat.
2. fiber.
3. protein.
4. carbohydrate.

4. carbohydrate.
Normally, the liver performs many metabolic functions that provide energy for the body. In cirrhosis, the liver’s metabolic function is compromised, increasing the client’s need for dietary carbohydrates and other energy sources to provide for cellular metabolism. The nurse should limit the client’s fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can’t metabolize protein efficiently. Increasing fiber intake isn’t significant for a client with cirrhosis.

The nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

1. a sedentary lifestyle and smoking.
2. a history of hemorrhoids and smoking.
3. alcohol abuse and a history of acute renal failure.
4. alcohol abuse and smoking.

4. alcohol abuse and smoking.
Risk factors for peptic (gastric and duodenal) ulcers include alcohol abuse, smoking, and stress. A sedentary lifestyle and a history of hemorrhoids aren’t risk factors for peptic ulcers. Chronic renal failure, not acute renal failure, is associated with duodenal ulcers.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

1. Acute pain related to biliary spasms
2. Deficient knowledge related to prevention of disease recurrence
3. Anxiety related to unknown outcome of hospitalization
4. Imbalanced nutrition: Less than body requirements related to biliary inflammation

1. Acute pain related to biliary spasms
The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can’t learn about prevention, may continue to experience anxiety, and can’t address nutritional concerns.

The nurse obtains a fingerstick glucose level of 45 mg/dl on the client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client’s skin is warm and dry. How should the nurse intervene?

1. Give the client 4 oz. of milk and a graham cracker containing peanut butter.
2. Obtain a serum glucose level
3. Obtain a repeat fingerstick glucose level.
4. Notify the physician.

3. Obtain a repeat fingerstick glucose level.The nurse should recheck the fingerstick glucose level to verify the original result because the client isn’t exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker containing peanut butter or a glass of orange juice after confirming the low glucose level. It isn’t necessary to notify the physician or to obtain a serum glucose level at this time.

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:

1. spironolactone (Aldactone).
2. phytonadione (Mephyton).
3. furosemide (Lasix).
4. warfarin (Coumadin).

2. phytonadione (Mephyton).
Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client’s PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (vitamin K1) to promote prothrombin synthesis. Spironolactone and furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin is an anticoagulant that prolongs PT.

The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?

1. Insulin is absorbed more slowly at abdominal injection sites than at other sites.
2. Insulin is absorbed rapidly regardless of the injection site.
3. Insulin is absorbed more rapidly at abdominal injection sites than at other sites.
4. Insulin is absorbed unpredictably at all injection sites.

3. Insulin is absorbed more rapidly at abdominal injection sites than at other sites.
Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection of the buttocks is less predictable.

For a client with cirrhosis, deterioration of hepatic function is best indicated by:

1. fatigue and muscle weakness.
2. difficulty in arousal.
3. nausea and anorexia.
4. weight gain.

2. difficulty in arousal.
Hepatic encephalopathy, a major complication of advanced cirrhosis, occurs when the liver no longer can convert ammonia (a by-product of protein breakdown) into glutamine. This leads to an increased blood level of ammonia — a central nervous system toxin — which causes a decrease in the level of consciousness. Fatigue, muscle weakness, nausea, anorexia, and weight gain occur during the early stages of cirrhosis.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client’s drinking history and other assessment findings. Which assessment findings confirm his diagnosis?

1. Recent weight loss and temperature elevation
2. Presence of blood in the client’s stool and recent hypertension
3. Presence of easy bruising and bradycardia
4. Adventitious breath sounds and hypertension

1. Recent weight loss and temperature elevation
Assessment findings associated with pancreatitis include recent weight loss and temperature elevation. Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that’s caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat. The assessment findings in option 2 aren’t associated with pancreatitis; fatty diarrhea and hypotension are usually present. Option 3 findings aren’t found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Option 4 findings aren’t associated with pancreatitis.

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1° C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes highest priority?

1. Deficient fluid volume related to osmotic diuresis
2. Decreased cardiac output related to elevated heart rate
3. Imbalanced nutrition: Less than body requirements related to insulin deficiency
4. Ineffective thermoregulation related to dehydration

1. Deficient fluid volume related to osmotic diuresis
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and fluid volume deficit. In this client, tachycardia is more likely to result from fluid volume deficit than from decreased cardiac output because his blood pressure is normal. Although the client’s serum glucose is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition: Less than body requirements isn’t appropriate. A temperature of 100.6° F isn’t life-threatening, eliminating ineffective thermoregulation as the top priority.

Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?

1. 70 units of neutral protamine Hagedorn (NPH) insulin and 30 units of regular insulin
2. 70 units of regular insulin and 30 units of NPH insulin
3. 70% NPH insulin and 30% regular insulin
4. 70% regular insulin and 30% NPH insulin

3. 70% NPH insulin and 30% regular insulin
Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.

A group of nursing assistants hired for the medical-surgical floors are attending hospital orientation. Which topic should the educator cover when teaching the group about caring for clients with diabetes?

1. Obtaining, reporting, and documenting fingerstick glucose levels
2. Treating a hypoglycemic reaction
3. Teaching the client dietary changes necessary with diabetes mellitus
4. Assessing the client experiencing a hypoglycemic reaction

1. Obtaining, reporting, and documenting fingerstick glucose levels
The educator should teach the nursing assistants how to obtain and document a fingerstick glucose level. She should also teach them normal and abnormal results and the importance of reporting them to the registered nurse caring for the client. Options 2, 3, and 4 are outside the scope of practice for a nursing assistant. They are the responsibility of the registered nurse.

Which laboratory finding is the primary diagnostic indicator for pancreatitis?

1. Elevated blood urea nitrogen (BUN)
2. Elevated serum lipase
3. Elevated aspartate aminotransferase (AST)
4. Increased lactate dehydrogenase (LD)

2. Elevated serum lipase
Elevation of serum lipase is the most reliable indicator of pancreatitis because this enzyme is produced solely by the pancreas. A client’s BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

The nurse is administering medications to a client diagnosed with hepatitis B. When the nurse hands the client his medications, the client says, “I would rather not take that pill or any others. I know there is no cure for hepatitis B.” The nurse recognizes that the client is expressing feelings of hopelessness about his diagnosis. Which response by the nurse respects the client’s rights concerning medication administration?

1. “You seem frustrated; however, you still must take this medication, it will help you.”
2. “Legally, I have to give you this medication.”
3. “You have the right to refuse any medication. Would you like to discuss your feelings about this disease.”
4. “I will document that you are noncompliant with your treatment regimen.”

3. “You have the right to refuse any medication. Would you like to discuss your feelings about this disease.”
Option 3 is the correct response. The client has the right to refuse any medical treatment, regardless of the consequences. The client is displaying hopelessness over the diagnosis; therefore, the nurse should encourage the client to discuss these feelings using therapeutic conversation. Options 1, 2, and 4 are inappropriate responses that are judgmental and dismiss the client’s feelings.

A client with diabetes mellitus has a prescription for 5 U of U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

1. Hyperglycemia
2. Hypoglycemia
3. Hyperuricemia
4. Hypochondria

2. Hypoglycemia
Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in contrast, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. Hyperuricemia refers to an abnormally large amount of uric acid in the blood. Hypochondria is abnormal anxiety about one’s health, with a false belief that one has a disease.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?

1. Accelerating the infusion if it falls behind schedule
2. Ensuring that the TPN tubing has an in-line filter
3. Monitoring the client’s weight every day
4. Recording fluid intake and output

3. Monitoring the client’s weight every day
By weighing the client every day, the nurse helps the team evaluate the client’s response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn’t accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

1. Jaundice
2. Pruritus of the arms and legs
3. Fatigue during ambulation
4. Irritability and drowsiness

4. Irritability and drowsiness
Although all the options are associated with hepatitis B, the onset of irritability and drowsiness suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness and should monitor the results of liver function tests, including the blood ammonia level. If hepatic function is decreased, the nurse should take safety precautions.

Which instruction about insulin administration should the nurse give to a client?

1. “Always follow the same order when drawing the different insulins into the syringe.”
2. “Shake the vials before withdrawing the insulin.”
3. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
4. “Discard the intermediate-acting insulin if it appears cloudy.”

1. “Always follow the same order when drawing the different insulins into the syringe.”
The client should be instructed always to follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin also should never be frozen because the insulin protein molecules may be damaged. Intermediate-acting insulin is normally cloudy.

A client with a history of alcohol abuse was admitted with bleeding esophageal varices. After several days of treatment, the client is ready for discharge. The nurse enters the client’s room to review discharge instructions with the client when he tells the nurse that he wants help quitting drinking. How should the nurse respond?

1. “Let me finish reviewing your discharge instructions, then we can discuss your concerns.”
2. “I’ll tell your family so they can make arrangements for you to enter an alcohol rehabilitation center.”
3. “I’ll notify your physician and call the social worker so she can discuss treatment options with you.”
4. “I hope it’s not too late; you’ve already done a lot of damage to your liver.”

3. “I’ll notify your physician and call the social worker so she can discuss treatment options with you.”
The nurse should notify the physician and call the social worker so the social worker can discuss treatment options with the client. The social worker may be able to arrange in-patient treatment for the patient immediately after discharge if the client wishes. Option 1 minimizes the client’s concerns; option 2 breeches client confidentiality; and option 4 is judgmental.

Laboratory studies indicate a client’s blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client’s glucose utilization?

1. A fasting blood glucose test
2. A 6-hour glucose tolerance test
3. A test of serum glycosylated hemoglobin (Hb A1c)
4. A test for urine ketones

3. A test of serum glycosylated hemoglobin (Hb A1c)
Hb A1c is the most reliable indicator of glucose utilization because it reflects blood glucose levels for the prior 3 months. While a fasting blood glucose test and 6-hour glucose tolerance test yield information about a client’s utilization of glucose, the results are influenced by other factors such as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose utilization but is limited in its diagnostic significance.

The nurse is explaining the action of insulin to a newly diagnosed diabetic client. During the teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when stating that insulin is secreted from the:

1. adenohypophysis.
2. beta cells of the pancreas.
3. alpha cells of the pancreas.
4. parafollicular cells of the thyroid.

2. beta cells of the pancreas.
The beta cells of the pancreas secrete insulin. The adenohypophysis or anterior pituitary gland secretes many hormones, such as growth hormone, prolactin, thyroid-stimulating hormone, corticotropin, follicle-stimulating hormone, and luteinizing hormone, but not insulin. The alpha cells of the pancreas secrete glucagon, which raises the blood glucose level. The parafollicular cells of the thyroid secrete the hormone calcitonin, which plays a role in calcium metabolism.

A client’s blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

1. Coma, anxiety, confusion, headache, and cool, moist skin.
2. Kussmaul’s respirations, dry skin, hypotension, and bradycardia.
3. Polyuria, polydipsia, hypotension, and hypernatremia.
4. Polyuria, polydipsia, polyphagia, and weight loss.

1. Coma, anxiety, confusion, headache, and cool, moist skin.
Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul’s respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

The physician prescribes spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

1. Serum potassium level of 3.5 mEq/L
2. Loss of 2 lb in 24 hours
3. Serum sodium level of 135 mEq/L
4. Blood pH of 7.25

2. Loss of 2 lb in 24 hours
Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client’s serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A client is taking glyburide (DiaBeta), 1.25 mg P.O. daily, to treat type 2 diabetes mellitus. Which statement indicates the need for further client teaching about management of this disease?

1. “I always carry hard candy to eat in case my blood sugar level drops.”
2. “I avoid exposure to the sun as much as possible.”
3. “I always wear my medical identification bracelet.”
4. “I often skip lunch because I don’t feel hungry.”

4. “I often skip lunch because I don’t feel hungry.”
A client who is receiving an oral antidiabetic agent should eat meals on a regular schedule because skipping a meal increases the risk of hypoglycemia. Carrying hard candy, avoiding exposure to the sun, and always wearing a medical identification bracelet indicate effective teaching.

A 71-year-old client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding would the nurse expect in this client?

1. Arterial pH 7.25
2. Plasma bicarbonate 12 mEq/L
3. Blood glucose level 1,300 mg/dl
4. Blood urea nitrogen 15 mg/dl

3. Blood glucose level 1,300 mg/dl
Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most frequently in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially the client produces large quantities of urine, if fluid intake isn’t increased at this time the client becomes dehydrated causing blood urea nitrogen levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits.

A client with type 1 diabetes mellitus has been on a regimen of multiple daily injection therapy. He’s being converted to continuous subcutaneous insulin therapy. While teaching the client about continuous subcutaneous insulin therapy, the nurse would be accurate in telling him the regimen includes the use of:

1. intermediate- and long-acting insulins.
2. short- and long-acting insulins.
3. short-acting insulin only.
4. short- and intermediate-acting insulins.

3. short-acting insulin only.
Continuous subcutaneous insulin regimen uses a basal rate and boluses of short-acting insulin. Multiple daily injection therapy uses a combination of short-acting and intermediate- or long-acting insulins.

Alterations in hepatic blood flow resulting from a drug interaction also can affect:

1. onset and duration.
2. distribution and excretion.
3. absorption and metabolism.
4. metabolism and excretion.

4. metabolism and excretion.
Alterations in hepatic blood flow resulting from a drug interaction can affect metabolism and excretion. Changes in hepatic blood flow don’t affect absorption, so a drug’s onset of action is also unchanged. Further, alterations in hepatic blood flow don’t affect distribution.

An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?

1. Nearly two-thirds of clients with diabetes mellitus are older than age 60.
2. Diabetes mellitus is more common in Hispanics and Blacks than in Whites.
3. Type 2 diabetes mellitus is less common than type 1 diabetes mellitus.
4. Approximately one-half of the clients diagnosed with type 2 are obese.

2. Diabetes mellitus is more common in Hispanics and Blacks than in Whites.
Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese.

The nurse is teaching a client with type 1 diabetes mellitus how to treat adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate. However, this treatment isn’t always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

1. Epinephrine
2. Glucagon
3. 50% dextrose
4. Hydrocortisone

2. Glucagon
During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can’t ingest an oral carbohydrate. Epinephrine isn’t a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn’t effective in reversing hypoglycemia.

A client with cholecystitis is receiving propantheline bromide. The client is given this medication because it:

1. reduces gastric solution production and hypermobility.
2. slows emptying of the stomach and reduces chyme in the duodenum.
3. inhibits contraction of the bile duct and gallbladder.
4. decreases bile secretions.

3. inhibits contraction of the bile duct and gallbladder.
Propantheline bromide is classified as a GI anticholinergic; the medication inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites. For gallbladder disease, propantheline has an antispasmodic effect on the bile duct and gallbladder. Although the medication reduces the production of gastric solutions as well as hypermobility, these aren’t the main reasons for the medication. The drug doesn’t slow emptying of the stomach or reduce chyme in the duodenum.

Which finding best indicates that the nursing assistant has an understanding of blood glucose meter use?

1. Verbalizing an understanding of blood glucose meter use
2. Documenting a normal blood glucose level
3. Providing documentation of previous certification
4. Demonstrating correct technique

4. Demonstrating correct technique
The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn’t demonstrate that the nursing assistant knows proper technique. Options 2 and 3 don’t demonstrate blood glucose meter use.

A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:

1. prefers to take insulin orally.
2. has type 2 diabetes.
3. has type 1 diabetes.
4. is pregnant and has type 2 diabetes.

2. has type 2 diabetes.
Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren’t effective in type 1 diabetes. Pregnant and lactating women aren’t prescribed oral antidiabetic agents because the effect on the fetus or breast-fed infant is uncertain.

The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:

1. encourage the client to ask questions about personal sexuality.
2. provide time for privacy.
3. provide support for the spouse or significant other.
4. suggest referral to a sex counselor or other appropriate professional.

4. suggest referral to a sex counselor or other appropriate professional.
The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling.

While obtaining a client’s medication history, the nurse learns that the client takes ranitidine (Zantac), as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The client should avoid taking a drug from which class with ranitidine?

1. Antacids
2. Antibiotics
3. Antipsychotics
4. Antiarrhythmics

1. Antacids
Because antacids can interact with ranitidine and interfere with its absorption, the client shouldn’t take these drugs together. Ranitidine doesn’t interact with antibiotic, antipsychotic, or antiarrhythmic agents.

The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

1. Elevated serum acetone level
2. Serum ketone bodies
3. Serum alkalosis
4. Below-normal serum potassium level

4. Below-normal serum potassium level
A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

1. Relieving abdominal pain
2. Preventing fluid volume overload
3. Maintaining adequate nutritional status
4. Teaching about the disease and its treatment

1. Relieving abdominal pain
The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse’s primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can’t help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

1. place the client in a private room.
2. wear a mask when handling the client’s bedpan.
3. wash the hands after touching the client.
4. wear a gown when providing personal care for the client.

3. wash the hands after touching the client.
To maintain enteric precautions, the nurse must wash the hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

A client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response?

1. “You could have gotten it by using I.V. drugs.”
2. “You must have received an infected blood transfusion.”
3. “You probably got it by engaging in unprotected sex.”
4. “You may have eaten contaminated restaurant food.”

4. “You may have eaten contaminated restaurant food.”
Hepatitis A virus typically is transmitted by the oral-fecal route — commonly by consuming food contaminated by infected food handlers. The virus isn’t transmitted by the I.V. route, blood transfusions, or unprotected sex. Hepatitis B can be transmitted by I.V. drug use or blood transfusion. Hepatitis C can be transmitted by unprotected sex.

A client is undergoing an extensive diagnostic workup for a suspected GI problem. The nurse discovers that the client has a family history of ulcer disease. Which blood type also is a risk factor for duodenal ulcers?

1. Type A
2. Type B
3. Type AB
4. Type O

4. Type O
Duodenal ulcers are more common in people with type O blood, suggesting a genetic basis. Types A, B, and AB blood aren’t associated with an increased incidence of duodenal ulcers.

For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?

1. They contain exudate and provide a moist wound environment.
2. They protect the wound from mechanical trauma and promote healing.
3. They debride the wound and promote healing by secondary intention.
4. They prevent the entrance of microorganisms and minimize wound discomfort.

3. They debride the wound and promote healing by secondary intention.
For this client, wet-to-dry dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry, sterile dressings protect the wound from mechanical trauma and promote healing.

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?

1. Administer half of the client’s typical morning insulin dose.
2. Administer an oral antidiabetic agent.
3. Administer an I.V. insulin infusion.
4. Administer the client’s normal daily dose of insulin.

1. Administer half of the client’s typical morning insulin dose.
If the nurse administers the client’s normal daily dose of insulin while he’s on nothing-by-mouth status before surgery, he’ll become hypoglycemic; half the daily insulin dose will provide all that’s needed. Oral antidiabetic agents aren’t effective for type 1 diabetes. I.V. insulin infusions aren’t necessary to manage blood glucose levels in clients undergoing routine surgery.

Because diet and exercise have failed to control a 63-year-old client’s blood glucose level, the client is prescribed glipizide (Glucotrol). After oral administration, the onset of action is:

1. 15 to 30 minutes
2. 30 to 60 minutes
3. 1 to 1½ hours
4. 2 to 3 hours

1. 15 to 30 minutes
Glipizide begins to act in 15 to 30 minutes. The other options are incorrect.

The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:

1. below 70 mg/dl.
2. between 70 and 120 mg/dl.
3. between 120 and 180 mg/dl.
4. over 180 mg/dl.

1. below 70 mg/dl.
A blood glucose level under 70 mg/dl is considered hypoglycemic. A normal blood glucose level is between 70 and 120 mg/dl. Over 120 mg/dl indicates hyperglycemia.

A client has type 1 diabetes. Her husband finds her unconscious at home and administers glucagon, 0.5 mg subcutaneously. She awakens in 5 minutes. Why should her husband offer a complex carbohydrate snack to her as soon as possible?

1. To decrease the possibility of nausea and vomiting
2. To restore liver glycogen and prevent secondary hypoglycemia
3. To stimulate her appetite
4. To decrease the amount of glycogen in her system

2. To restore liver glycogen and prevent secondary hypoglycemia
A client with type 1 diabetes who requires glucagon should be given a complex carbohydrate snack as soon as possible to restore the liver glycogen and prevent secondary hypoglycemia. A complex carbohydrate snack doesn’t decrease the possibility of nausea and vomiting or stimulate the appetite, and it increases the amount of glycogen in the system.

A client is admitted with suspected cirrhosis. During assessment, the nurse is most likely to detect:

1. an increase in chest hair.
2. muscle wasting.
3. testicular hypertrophy.
4. an increased clotting tendency.

2. muscle wasting.
Cirrhosis causes muscle wasting, a decrease in chest and axillary hair, testicular atrophy, and an increased bleeding tendency.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

1. yellow sclerae.
2. light amber urine.
3. circumoral pallor.
4. black, tarry stools.

1. yellow sclerae.
Yellow sclerae may be the first sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don’t occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client has a diagnosis of type 2 diabetes mellitus. The physician prescribes tolazamide (Tolinase), 100 mg P.O. daily. How does the onset of action of tolazamide compare with that of the other sulfonylureas?

1. All sulfonylureas, including tolazamide, have a slow onset of action.
2. All sulfonylureas, including tolazamide, have an immediate onset of action.
3. Tolazamide has a slower onset of action than the other sulfonylureas.
4. Tolazamide has a faster onset of action than the other sulfonylureas.

3. Tolazamide has a slower onset of action than the other sulfonylureas.
Tolazamide has a slower onset of action than other sulfonylureas.

A client with type 1 diabetes mellitus is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first?

1. Initiate fluid replacement therapy.
2. Administer insulin.
3. Correct diabetic ketoacidosis.
4. Determine the cause of diabetic ketoacidosis.

1. Initiate fluid replacement therapy.
The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won’t circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client’s condition must be stabilized first to prevent life-threatening complications.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client’s vital signs are stable, but the client’s pain is worsening and radiating to his back. Which intervention takes priority for this client?

1. Placing the client in a semi-Fowler’s position
2. Maintaining nothing-by-mouth status
3. Administering morphine I.V. as prescribed
4. Providing mouth care

3. Administering morphine I.V. as prescribed
The nurse should address the client’s pain issues first by administering morphine I.V. as prescribed. The other interventions don’t take priority over addressing the client’s pain issues.

The graduate nurse and her preceptor are establishing priorities for their morning assessments. Which client should they assess first?

1. The newly admitted client with acute abdominal pain
2. The client who underwent surgery three days ago and who now requires a dressing change
3. The client receiving continuous tube feedings who needs the tube-feeding residual checked
4. The sleeping client who received pain medication 1 hour ago

1. The newly admitted client with acute abdominal pain
The graduate nurse and her preceptor should assess the new admission with acute abdominal pain first because he just arrived on the floor and might be unstable. Next, they should change the abdominal dressing for the postoperative client or measure feeding tube residual in the client with continuous tube feedings. These tasks are of equal importance. They should assess the sleeping client who received pain medication 1 hour ago last because he just received relief from his pain and is able to sleep.

A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone (Maalox TC) P.O. 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

1. It has a slow onset of action.
2. It has a short duration of action.
3. It has a prolonged half-life.
4. It’s highly metabolized.

2. It has a short duration of action.
Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don’t have prolonged half-lives, and aren’t highly metabolized.

When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which possible adverse effect of the drug?

1. Constipation
2. Menstrual irregularities
3. Hypokalemia
4. Hypernatremia

2. Menstrual irregularities
Spironolactone can cause menstrual irregularities and decreased libido. Men may also experience gynecomastia and impotence. Diarrhea, hyponatremia, and hyperkalemia are also adverse effects of spirolactone.

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:

1. whole blood and albumin.
2. platelets and packed red blood cells.
3. fresh frozen plasma and whole blood.
4. cryoprecipitate and fresh frozen plasma.

4. cryoprecipitate and fresh frozen plasma.
The liver is vital in the synthesis of clotting factors, so when it’s diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering blood products that aid clotting. These include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors. Although administering whole blood, albumin, and packed cells will contribute to hemostasis, those products aren’t specifically used to treat hemostasis. Platelets are helpful, but the best answer is cryoprecipitate and fresh frozen plasma.

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. Her family reports that she has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

1. Inserting a feeding tube and providing tube feedings
2. Administering a 500-ml bolus of normal saline solution
3. Administering 1 ampule of 50% dextrose solution, per physician’s order
4. Observing the client for 1 hour, then rechecking the fingerstick glucose level

3. Administering 1 ampule of 50% dextrose solution, per physician’s order
The nurse should administer 50% dextrose solution to restore the client’s physiological integrity. Feeding through a feeding tube isn’t appropriate for this client. A bolus of normal saline solution doesn’t provide the client with the much needed glucose. Observing the client for 1 hour delays treatment. The client’s blood glucose level could drop further during this time, placing her at risk for irreversible brain damage.

On a medical surgical floor, the nurse is caring for a cluster of clients who were diagnosed with diabetes mellitus. Which client should the nurse assess first?

1. An 80-year-old client with a blood glucose level of 350 mg/dl
2. A 20-year-old client with a blood glucose level of 70 mg/dl
3. A 60-year-old client experiencing nausea and vomiting
4. A 55-year-old complaining of chest pressure

4. A 55-year-old complaining of chest pressure
The nurse should assess the client with chest pressure first because he might be experiencing a myocardial infarction. The blood glucose levels in options 2 and 3 are abnormal, but not life threatening; therefore, those clients don’t require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:

1. Trousseau’s sign.
2. Homans’ sign.
3. Hegar’s sign.
4. Goodell’s sign.

1. Trousseau’s sign.
This client’s serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau’s sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans’ sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar’s sign (softening of the uterine isthmus) and Goodell’s sign (cervical softening) are probable signs of pregnancy.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

1. Applying a heating pad
2. Debriding the wound three times per day
3. Using sterile technique during the dressing change
4. Cleaning the wound with a povidone-iodine solution

3. Using sterile technique during the dressing change
The nurse should perform the dressing changes using sterile technique to prevent infection. Heating application should be avoided in a client with diabetes because of the risk for injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

1. Recent weight gain of 20 lb
2. Failure to monitor blood glucose levels
3. Skipping insulin doses during illness
4. Crying whenever diabetes is mentioned

4. Crying whenever diabetes is mentioned
A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

A client, age 23, is diagnosed with diabetes mellitus. The physician prescribes 15 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

1. Inject 35 U air into NPH vial; inject 15 U air into regular insulin vial, withdraw 15 U regular insulin; withdraw 35 U NPH.
2. Inject 15 U air into regular insulin vial; inject 35 U air into NPH vial, withdraw 35 U of NPH; withdraw 15 U regular insulin.
3. Inject 15 U air into regular insulin vial, withdraw 15 units of regular insulin; inject 35 U air into NPH vial and withdraw 35 U NPH.
4. Inject 35 U air into NPH vial; inject 15 U air into regular insulin vial; withdraw 35 U NPH; withdraw 15 U regular insulin.

1. Inject 35 U air into NPH vial; inject 15 U air into regular insulin vial, withdraw 15 U regular insulin; withdraw 35 U NPH.
To avoid creating a vacuum, the nurse must inject exactly the same amount of air into a multidose vial to replace the amount of medication to be withdrawn. Follow these steps: (1) Inject air into the vial from which the second insulin dose will be withdrawn (isophane insulin). (2) Inject air into the vial from which insulin will be withdrawn first (regular insulin). (3) With the needle inserted into the regular insulin vial, withdraw the correct amount. (4) With 15 U of regular insulin in the syringe, carefully withdraw 35 U of NPH, for a total of 50 U in the syringe. Options 2 and 4 are incorrect because regular insulin must be withdrawn first. Option 3 is incorrect because the nurse must not insert air into a multiple-dose vial with a syringe containing medication.

A client who was diagnosed with type 1 diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client’s blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

1. Cool, moist skin
2. Rapid, thready pulse
3. Arm and leg trembling
4. Slow, shallow respirations

2. Rapid, thready pulse
This client’s abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

The nurse is teaching the client about risk factors for diabetes mellitus. Which risk factor for diabetes mellitus is nonmodifiable?

1. Poor control of blood glucose levels
2. Inappropriate foot care
3. Current or recent foot trauma
4. Advanced age

4. Advanced age
Nonmodifiable risk factors are ones that the client doesn’t have the ability to change. Therefore, advanced age is the correct answer. The other choices are ones over which the client can exert some control.

When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the-counter preparation that can interact with insulin?

1. Antacids
2. Acetaminophen preparations
3. Vitamins with iron
4. Salicylate preparations

4. Salicylate preparations
Salicylates may interact with insulin to cause hypoglycemia. Antacids, acetaminophen preparations, and vitamins with iron don’t interact with insulin.

The physician prescribes lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:

1. urine output.
2. abdominal girth.
3. stool frequency.
4. level of consciousness (LOC).

4. level of consciousness (LOC).
In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client’s LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

A client with diabetic ketoacidosis (DKA) was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?

1. Infuse 500 ml of normal saline solution over 1 hour.
2. Hold insulin infusion for 30 minutes.
3. Add 40 mEq KCL to an infusion of half normal saline solution and infuse at a rate of 10 mEq/hour.
4. Change the second I.V. solution to dextrose 5% in water.

4. Change the second I.V. solution to dextrose 5% in water.
The nurse should question the physician’s order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until the client’s blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client’s urine output is low and his specific gravity is high which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level, places the client at risk for life-threatening cardiac arrhythmias.

A client is admitted with a serum glucose level of 618 mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6° F (38.1° C); a heart rate of 116 beats/min; and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority?

1. Deficient fluid volume related to osmotic diuresis
2. Decreased cardiac output related to increased heart rate
3. Imbalanced nutrition: Less than body requirements related to insulin deficiency
4. Ineffective thermoregulation related to dehydration

1. Deficient fluid volume related to osmotic diuresis
A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and fluid volume deficit. In this client, tachycardia is more likely to result from a fluid volume deficit than from decreased cardiac output because the blood pressure is normal. Although the client’s serum glucose level is elevated, food isn’t a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, Imbalanced nutrition: Less than body requirements isn’t an appropriate nursing diagnosis. A temperature of 100.6° F (38.1° C) isn’t life-threatening, eliminating Ineffective thermoregulation as the top priority.

A client is admitted to the medical intensive care unit with a diagnosis of pancreatitis. Which nursing intervention is most appropriate?

1. Providing generous servings at mealtime
2. Reserving an antecubital site for a peripherally inserted central catheter (PICC)
3. Providing the client with plenty of P.O. fluids
4. Limiting I.V. fluid intake according to the physician’s order

2. Reserving an antecubital site for a peripherally inserted central catheter (PICC)
Pancreatitis treatment typically involves resting the GI tract by maintaining nothing-by-mouth status. The nurse should reserve the antecubital site for a PICC, which enables the client to receive long-term total parenteral nutrition. Clients in the acute stages of pancreatitis also require large volumes of I.V. fluids to compensate for fluid loss.

The nurse and the nursing assistant are caring for a paraplegic client admitted with peptic ulcer disease. Which intervention should be performed by the registered nurse?

1. Repositioning the client
2. Teaching the client about consuming a bland diet
3. Measuring the client’s blood pressure
4. Measuring urinary output

2. Teaching the client about consuming a bland diet
The registered nurse should teach the client about consuming a bland diet. Unlicensed assistive personnel aren’t educated to teach clients about specialty diets. Repositioning the client, measuring blood pressure, and measuring urinary output are all tasks that can be performed by a nursing assistant.

A 78-year-old client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dL; BUN: 12 mg/dL; Creatinine: 0.9 mg/dL; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?

1. CO2
2. Sodium
3. Chloride
4. Potassium

4. Potassium
A normal potassium level is 3.8 to 5.5mEq/L. Severe hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release of insulin and results in glucose intolerance. The glucose level is above normal (normal is 75 to 110 mg/dL) and the chloride level is a bit low (normal is 100 to 110 mEq/L). Although these levels should be reported, neither is life-threatening. The BUN (normal is 8 to 26 mg/dL) and creatinine (normal is 0.8 to 1.4 mg/dL) are within normal range.

The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:

1. I.M. or subcutaneous glucagon.
2. I.V. bolus of dextrose 50%.
3. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
4. 10 U of fast-acting insulin.

3. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
This client is having a hypoglycemic episode. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer either I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn’t administer insulin to a client who’s hypoglycemic; this action will further compromise the client’s condition.

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client’s nasogastric (NG) tube has stopped draining. How should the nurse respond?

1. Notify the physician
2. Reposition the tube
3. Irrigate the tube
4. Increase the suction level

1. Notify the physician
An NG tube that fails to drain during the postoperative period should be reported to the physician immediately. It may be clogged, which could increase pressure on the suture site because fluid isn’t draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.

A client is evaluated for type 1 diabetes mellitus. Which client comment correlates best with this disorder?

1. “I’m thirsty all the time. I just can’t get enough to drink.”
2. “It seems like I have no appetite. I have to make myself eat.”
3. “I have a cough and cold that just won’t go away.”
4. “I notice pain when I urinate.”

1. “I’m thirsty all the time. I just can’t get enough to drink.”
Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite). Decreased appetite, lingering cough and cold, and pain on urination aren’t related to diabetes. Decreased appetite reflects a GI disorder; cough and cold indicate an upper respiratory problem; and pain on urination suggests a urinary tract infection (UTI).

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias.

1. Serum potassium level
2. Serum calcium level
3. Serum sodium level
4. Serum chloride level

1. Serum potassium level
During periods of acidosis, potassium leaves the cell causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell causing hypokalemia if levels aren’t monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don’t typically cause cardiac arrhythmias.

The physician diagnoses type 1 diabetes mellitus in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe:

1. beef insulin.
2. fish insulin.
3. human insulin.
4. pork insulin.

3. human insulin.
Human insulin is the least antigenic form of insulin because its composition is identical to that of endogenous insulin. Animal insulins, such as beef, fish, and pork insulins, differ in composition from endogenous insulin and are therefore more antigenic.

An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

1. 2 to 5 g of a simple carbohydrate.
2. 10 to 15 g of a simple carbohydrate.
3. 18 to 20 g of a simple carbohydrate.
4. 25 to 30 g of a simple carbohydrate.

2. 10 to 15 g of a simple carbohydrate.
To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?

1. “Be sure to take glipizide 30 minutes before meals.”
2. “Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly.”
3. “You won’t need to check your blood glucose level after you start taking glipizide.”
4. “Take glipizide after a meal to prevent heartburn.”

1. “Be sure to take glipizide 30 minutes before meals.”
The client should take glipizide twice per day, 30 minutes before a meal, because food decreases its absorption. The drug doesn’t cause hyponatremia and therefore doesn’t necessitate monthly serum sodium measurement. The client must continue to monitor blood glucose levels during glipizide therapy.

While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery primarily to:

1. increase respiratory effectiveness.
2. eliminate the need for nasogastric intubation.
3. improve nutritional status during recovery.
4. decrease the amount of postoperative analgesia needed.

1. increase respiratory effectiveness.
The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. Therefore, incentive spirometry is used to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Incentive spirometry has no effect on intubation, nutrition, or analgesia.

A client with type 1 diabetes mellitus takes 15 U of Humulin N insulin before breakfast and 8 U before dinner. During a follow-up visit, the nurse reevaluates the client’s knowledge about insulin therapy and self-administration skills and learns that the client is unaware that certain over-the-counter (OTC) preparations and other medications may interact with insulin. The nurse should advise the client to avoid which OTC preparations?

1. Antacids
2. Salicylate-containing preparations
3. Vitamins with iron
4. Acetaminophen-containing preparations

2. Salicylate-containing preparations
Salicylates may interact with insulin, causing hypoglycemia. Antacids, vitamins with iron, and acetaminophen aren’t known to interact with insulin.

The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:

1. 30% to 35% carbohydrate, 40% fat, and 25% to 30% protein.
2. 40% to 45% carbohydrate, 40% fat, and 15% to 20% protein.
3. 50% to 55% carbohydrate, 35% fat, and 10% to 15% protein.
4. 55% to 60% carbohydrate, 30% fat, and 10% to 15% protein.

4. 55% to 60% carbohydrate, 30% fat, and 10% to 15% protein.
A client with diabetes mellitus should get 55% to 60% of total daily calories from carbohydrates, no more than 30% from fats, and the remainder (10% to 15%) from proteins. A diet in which carbohydrates account for less than 55% of calories has a higher fat content than recommended for a healthy diet. Because diabetes mellitus is a risk factor for cardiovascular disease, excessive fat intake further increases the client’s risk for cardiovascular disease.

When teaching a client about insulin administration, the nurse should include which instruction?

1. “Take insulin after the first meal of the day.”
2. “Inject insulin at a 45-degree angle into the deltoid muscle.”
3. “Shake the insulin vial vigorously before withdrawing the medication.”
4. “Draw up clear insulin first when mixing two types of insulin in one syringe.”

4. “Draw up clear insulin first when mixing two types of insulin in one syringe.”
When mixing two types of insulin, the client should draw clear (regular) insulin into the syringe first. The daily insulin dose typically is administered before the first meal of the day and is injected into fatty tissue at a 90-degree angle. If cloudy (NPH or Humulin N) insulin must be administered, the client should roll the vial between the palms gently before withdrawing the medication.

A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

1. “Inject insulin into healthy tissue with large blood vessels and nerves.”
2. “Rotate injection sites within the same anatomic region, not among different regions.”
3. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
4. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

2. “Rotate injection sites within the same anatomic region, not among different regions.”
The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily.

A client with newly diagnosed type 2 diabetes mellitus is admitted to the metabolic unit. The primary goal for this admission is education. Which of the following goals should the nurse incorporate into her teaching plan?

1. Maintenance of blood glucose levels between 180 and 200 mg/dl
2. Smoking reduction but not complete cessation
3. An eye examination every 2 years until age 50
4. Exercise and a weight reduction diet

4. Exercise and a weight reduction diet
Type 2 diabetes is often obesity-related; therefore, weight reduction may enhance the normalization of the blood glucose level. Weight reduction should be achieved by a healthy diet and exercise to increase carbohydrate metabolism. Blood glucose levels should be maintained within normal limits to prevent the development of diabetic complications. Clients with type 1 or 2 diabetes shouldn’t smoke because of the increased risk of cardiovascular disease. A funduscopic examination should be done yearly to identify early signs of diabetic retinopathy.

The nurse is developing a care plan for a client with hepatitis A. What is the main route of transmission of this hepatitis virus?

1. Sputum
2. Feces
3. Blood
4. Urine

2. Feces
The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn’t transmitted by way of sputum, blood, or urine. However, the hepatitis B virus is transmitted primarily through contact with contaminated blood, human secretions, and feces.

After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. What would the nurse expect the physician to do?

1. Initiate insulin therapy.
2. Switch the client to a different oral antidiabetic agent.
3. Prescribe an additional oral antidiabetic agent.
4. Restrict carbohydrate intake to less than 30% of the total caloric intake.

2. Switch the client to a different oral antidiabetic agent.
Many clients (25% to 60%) with secondary failure respond to a different oral antidiabetic agent. Therefore, it wouldn’t be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin may be used in addition to the antidiabetic agent.

A client with long-standing type 1 diabetes mellitus is admitted to the hospital with unstable angina pectoris. After the client’s condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

1. Impaired adjustment.
2. Defensive coping.
3. Deficient knowledge (treatment regimen).
4. Health-seeking behaviors (diabetes control).

3. Deficient knowledge (treatment regimen).
The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify the lifestyle as needed to manage the disease. This eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client’s health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn’t warranted.

Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?

1. Administer 2 to 3 L of I.V. fluid rapidly.
2. Administer 6 L of I.V. fluid over the first 24 hours.
3. Administer a dextrose solution containing normal saline solution.
4. Administer I.V. fluid slowly to prevent circulatory overload and collapse.

1. Administer 2 to 3 L of I.V. fluid rapidly.
Regardless of the client’s medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client’s stools to be:

1. coffee-ground-like.
2. clay-colored.
3. black and tarry.
4. bright red.

3. black and tarry.
Black, tarry stools are a sign of bleeding high in the GI tract, as from a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI tract bleeding commonly is described as coffee-ground-like. Clay-colored stools are associated with biliary obstruction. Bright red stools indicate lower GI tract bleeding.

A client has just been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?

1. “You’ll need more insulin when you exercise or increase your food intake.”
2. “You’ll need less insulin when you exercise or reduce your food intake.”
3. “You’ll need less insulin when you increase your food intake.”
4. “You’ll need more insulin when you exercise or decrease your food intake.”

2. “You’ll need less insulin when you exercise or reduce your food intake.”
Exercise, reduced food intake, hypothyroidism, and certain medications decrease insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness, increased insulin antibodies, and certain medications increase insulin requirements.

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

1. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
2. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
3. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
4. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

1. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn’t need to monitor blood glucose levels. A high-carbohydrate diet would exacerbate the client’s condition, particularly if fluid intake is low.

When evaluating a client for complications of acute pancreatitis, the nurse would observe for:

1. increased intracranial pressure.
2. decreased urine output.
3. bradycardia.
4. hypertension.

2. decreased urine output.Acute pancreatitis can cause decreased urine output, which results from the renal failure that sometimes accompanies this condition. Intracranial pressure neither increases nor decreases in a client with pancreatitis. Tachycardia, not bradycardia, usually is associated with pulmonary or hypovolemic complications of pancreatitis. Hypotension can be caused by a hypovolemic complication, but hypertension usually isn’t related to acute pancreatitis.
Patient Education for Peptic Ulcer Disease
a. Avoid consuming alcohol and substances that contain caffeine or chocolate.
b. Avoid smoking.
c. Avoid aspirin or NSAIDs.
d. Obtain adequate rest and reduce stress.
Surgical Interventions for Gastric Ulcers
Total gastrectomy
Vagotomy
Gastric resection
Billroth I
Billroth II
Pyloroplasty
Total gastrectomy
Surgical intervention for gastric ulcers
Removal of the stomach with attachment of the esophagus to the jejunum or duodenum; also called esophagojejunostomy or esophagoduodenostomy
Vagotomy
Surgical intervention for gastric ulcers
Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach
Gastric resection
Surgical intervention for gastric ulcers
Removal of the lower half of the stomach and usually includes a vagotomy; also called antrectomy
Billroth I
Surgical intervention for gastric ulcers
Partial gastrectomy, with the remaining segment anastomosed to the duodenum; also called gastroduodenostomy
Billroth II
Surgical intervention for gastric ulcers
Partial gastrectomy, with the remaining segment anastomosed to the jejunum; also called gastrojejunostomy
Pyloroplasty
Surgical intervention for gastric ulcers
Enlargement of the pylorus to prevent or decrease pyloric obstruction, thereby enhancing gastric emptying
Duodenal ulcer
a break in the mucosa of the duodenum
Risk factors for duodenal ulcers
infection with H. pylori; alcohol intake; smoking; stress; caffeine; the use of aspirin, corticosteroids, and NSAIDs
Complications of duodenal ulcers
bleeding, perforation, gastric outlet obstruction, and intractable disease
Interventions for gastric ulcers
Monitor vital signs.
Instruct the client about a bland diet, with small frequent meals.
Provide for adequate rest.
Encourage the cessation of smoking.
Instruct the client to avoid alcohol intake, caffeine, the use of aspirin, corticosteroids, and NSAIDs.
fAdminister medications to treat H. pylori and antacids to neutralize acid secretions as prescribed.
Administer H2-receptor antagonists or proton pump inhibitors as prescribed to block the secretion of acid.
Esophageal Varices
Dilated and tortuous veins in the submucosa of the esophagus – Caused by portal hypertension, often associated with liver cirrhosis; are at high risk for rupture if portal circulation pressure rises
Assessment/signs/symptoms for esophageal varices
Hematemesis; Melena; Tarry stools; Ascites; Jaundice; Hepatomegaly; splenomegaly; Dilated abdominal veins; Signs of shock
Drugs that can cause upper GI bleed
corticosteroids, aspirin, NSAIDs
Type 1 diabetes mellitus
a nearly absolute deficiency of insulin due to detruction of beta cells; if insulin is not given, fats are metabolized for energy, resulting in ketonemia (acidosis) – onset of hyperglycemic symptoms are more rapid and acute
Type 2 diabetes mellitus
a relative lack of insulin or resistance to the action of insulin; usually, insulin is sufficient to stabilize fat and protein metabolism but not carbohydrate metabolism – genetically determined defects in insulin receptors – obesity decreases insulin receptor sites – leads to beta cell secretory exhaustion
Signs and symptoms of diabetes mellitus
a. Polyuria, polydipsia, polyphagia (more common in type 1 diabetes mellitus)
b. Hyperglycemia (126 or > fasting)
c. Weight loss (common in type 1 diabetes mellitus, rare in type 2 diabetes mellitus)
d. Blurred vision
e. Slow wound healing
f. Vaginal infections
g. Weakness and paresthesias
h. Signs of inadequate circulation to the feet
i. Signs of accelerated atherosclerosis (renal, cerebral, cardiac, peripheral)
Functions of Insulin
enables glucose to be transported across cell membrane
converts glucose into glycogen for storage in liver and muscles
helps excess glucose be converted to fat
prevents protein breakdown for energy
Counterregulatory hormones
stimulate glycogen release – glucagon, epinephrine, growth hormone, cortisol, somastatin
Normal blood glucose level
80 – 20 mg/dl
Hypoglycemia lab value
glucose < 50 mg/dl
Causes of hypoglycemia
too much insulin
too little food
unusual amounts of exercise
delayed eating
Signs and symptoms of hypoglycemia
cold sweats – weakness – trembling – nervousness – irritability – pallor – increased heart rate – confusion – altered LOC and irrational behavior (cerebral glucose defecit)
Diet and diabetes
a. The total number of calories is individualized based on the client’s current or desired weight and the presence of other existing health problems.
b. Day-to-day consistency in timing and amount of food intake helps control the blood glucose level.
c. As prescribed by the physician, the client may be advised to follow the food exchange recommendations of the American Diabetic Association
d. Carbohydrate counting may be a simpler approach for some clients; it focuses on the total grams of carbohydrates eaten per meal. The client may be more compliant with carbohydrate counting, resulting in better glycemic control; it is usually necessary for clients undergoing intense insulin therapy.
e. Incorporate the diet into individual client needs, lifestyle, and cultural and socioeconomic patterns.
Rapid acting insulin
onset: 15 minutes
peak: 1 hour
duration: 2 – 4 hours
*do not delay eating
Humalog
rapid acting insulin
Novolog
rapid acting insulin
Aprida
rapid acting insulin
Short acting insulin (regular)
onset: 30 minutes
peak: 2 – 3 hours
duration: 3 – 6 hours
* may be administered IV (DKA)
Intermediate acting insulin
onset: 2 – 4 hours
peak: 4 – 12 hours
duration: 12 – 18 hours
*often used in combination with short acting insulin
NPH
intermediate acting insulin
Long acting insulin
onset: 6 – 10 hours
peak: varies
duration: 18 – 24 hours
* do not mix with other insulins
* take at same time every day
Lantus
long acting insulin
onset: 2 – 4 hours
Complications of insulin therapy
Local allergic reactions
Insulin lipodystrophy
Lipohypertrophy
Insulin resistance
Local allergic reactions to insulin therapy
redness, swelling, tenderness, and induration or a wheal at the site of injection may occur 1 to 2 hours after administration – reactions usually occur during the early stages of insulin therapy
Insulin lipodystrophy
loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat; the use of human insulin helps prevent this complication
Lipohypertrophy
development of fibrous fatty masses at the injection site and is caused by repeated use of an injection site – Instruct the client to avoid injecting insulin into affected sites. and about the importance of rotating insulin injection at one anatomical site
Insulin resistance
The client receiving insulin develops immune antibodies that bind the insulin, thereby decreasing the insulin available for use in the body.
Treatment consists of administering a purer insulin preparation
Dawn phenomenon
results from reduced tissue sensitivity to insulin that usually develops between 5 and 8 AM (prebreakfast hyperglycemia occurs); it may be caused by nocturnal release of growth hormone
Treatment includes administering an evening dose (or increasing the amount of a current dose) of intermediate-acting insulin at about 10 PM.
Somogyi effect
Normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2 to 3 AM, which causes an increase in the production of counterregulatory hormones.
By about 7 AM, in response to the counterregulatory hormones, the blood glucose rebounds significantly to the hyperglycemic range.
Treatment includes decreasing the evening (predinner or bedtime) dose of intermediate-acting insulin or increasing the bedtime snack.
Alpha – Glucosidase Inhibitors
slow sugar absorption in the gut – blocks enzymes that digest starches
Taken with meals
Side effects: gas, bloating, diarrhea
ie. Precose, Glyset
Sulfonylureas
Increase insulin production by pancreas by stimulating beta cells – also increases receptor sensitivity
1st and 2nd generation – 2nd gen have fewer side effects and more expensive
Used in patients > 40 w/ diabetes < 5 years
ie. Diabinese, Glucotrol, Amaryl
Thiazolidinediones
Increase uptake of sugar by muscle and fat cells – also reduce glucose production in the liver
ie. Actos
Biguanides
Decreases glucose production by the liver and makes muscle more sensitive to insulin
Less likely to cause hypoglycemic reaction
Help improve lipid levels
Do not take if kidney disease
Side effects: nausea, diarrhea, metallic taste in mouth
ie. Glucophage (metformin)
Meglitinides
Stimulate the beta cells to release more insulin
Byetta
Signals the pancreas to make the right amount of insulin after eating – stops the liver from making too much glucose – slows how quickly food leaves the stomach – may reduce appetite and aid in weight loss
Exercise and diabetes
Exercise lowers the blood glucose level, encourages weight loss, reduces cardiovascular risks, improves circulation and muscle tone, decreases total cholesterol and triglyceride levels, and decreases insulin resistance and glucose intolerance.
Instruct the client in dietary adjustments when exercising; dietary adjustments are individualized.
If the client requires extra food during exercise to prevent hypoglycemia, it need not be deducted from the regular meal plan.
If the blood glucose level is higher than 250 mg/ dL and urinary ketones (type 1 diabetes mellitus) are present, the client is instructed not to exercise until the blood glucose level is closer to normal and urinary ketones are absent.
3 Levels of diabetic education
level 1 – blood glucose monitoring, insulin admin, s&s of hypoglycemia and hyperglycemia
level 2 – maintaining blood glucose level, diet management, sick day guidelines
level 3 – effects exercise, adjusting insulin and lifestyle, stress management
Diabetic Ketoacidosis
life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs – manifested by hyperglycemia, dehydration, ketosis, and acidosis – sudden onset
Interventions for DKA
Restore circulating blood volume and protect against cerebral, coronary, and renal hypoperfusion.
Treat dehydration with rapid IV infusions of 0.9% or 0.45% normal saline (NS) as prescribed; dextrose is added to IV fluids (D 5NS, or 5% dextrose in 0.45% saline) when the blood glucose level reaches 250 to 300 mg/ dL.
Treat hyperglycemia with regular insulin administered intravenously as prescribed.
Correct electrolyte imbalances (potassium level may be elevated as a result of dehydration and acidosis).
Monitor potassium level closely because when the client receives treatment for the dehydration and acidosis, the serum potassium level will decrease and potassium replacement may be required.
HHNK/HHNS
Extreme hyperglycemia occurs without ketosis or acidosis.
The syndrome occurs most often in individuals with type 2 diabetes mellitus.
The major difference between HHNS and DKA is that ketosis and acidosis do not occur with HHNS; enough insulin is present with HHNS to prevent breakdown of fats for energy, thus preventing ketosis.
Treatment for HHNS
Treatment is similar to that for DKA – includes fluid replacement, correction of electrolyte imbalances, and insulin administration.
Fluid replacement in the older client must be done very carefully because of the potential for heart failure.
Insulin plays a less critical role in the treatment of HHNS than it does for the treatment of DKA because ketosis and acidosis do not occur; rehydration alone may decrease glucose levels.
Diabetic retinopathy
Chronic and progressive impairment of the retinal circulation that eventually causes hemorrhage. Permanent vision changes and blindness can occur. The client has difficulty with carrying out the daily tasks of blood glucose testing and insulin injections.
Diabetic nephropathy
Progressive decrease in kidney function
Diabetic neuropathy
General deterioration of the nervous system throughout the body b. Complications include the development of nonhealing ulcers of the feet, gastric paresis, and erectile dysfunction.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which of the following anticipated physician’s prescriptions?

1. Endotracheal intubation
2. 100 units of NPH insulin
3. Intravenous infusion of normal saline
4. Intravenous infusion of sodium bicarbonate

3. Intravenous infusion of normal saline
Rationale: The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS.

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump:

1. Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals
2. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels
3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream
4. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

4. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal
Rationale: An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency department. Which finding would a nurse expect to note as confirming this diagnosis?

1. Comatose state
2. Decreased urine output
3. Increased respirations and an increase in pH
4. Elevated blood glucose level and low plasma bicarbonate level

4. Elevated blood glucose level and low plasma bicarbonate level
Rationale: In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/ L, the blood glucose level is higher than 250 mg/ dL, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul’s respirations would be present . A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

A nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which of the following symptoms develops?

1. Polyuria
2. Shakiness
3. Blurred vision
4. Fruity breath odor

2. Shakiness
Rationale: Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose. A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

A client with diabetes mellitus demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The appropriate intervention to decrease the client’s anxiety is to:

1. Administer a sedative.
2. Convey empathy, trust, and respect toward the client.
3. Ignore the signs and symptoms of anxiety so that they will soon disappear.
4. Make sure that the client knows all the correct medical terms to understand what is happening.

2. Convey empathy, trust, and respect toward the client.
Rationale: The appropriate intervention is to address the client’s feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client’s anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

A nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client states:

1. “I will stop taking my insulin if I’m too sick to eat.”
2. “I will decrease my insulin dose during times of illness.”
3. “I will adjust my insulin dose according to the level of glucose in my urine.”
4. “I will notify my physician if my blood glucose level is higher than 250 mg/ dL.”

4. “I will notify my physician if my blood glucose level is higher than 250 mg/ dL.”
Rationale: During illness, the client should monitor blood glucose levels and should notify the physician if the level is higher than 250 mg/ dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the physician’s advice and are usually adjusted based on blood glucose levels, not urinary glucose readings.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/ dL. A continuous intravenous infusion of regular insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/ dL. The nurse would next prepare to administer which of the following?

1. Ampule of 50% dextrose
2. NPH insulin subcutaneously
3. Intravenous fluids containing 5% dextrose
4. Phenytoin (Dilantin) for the prevention of seizures

3. Intravenous fluids containing 5% dextrose
Rationale: During management of DKA, when the blood glucose level falls to 250 to 300 mg/ dL, the infusion rate is reduced and a 5% dextrose in 0.45% saline is added to maintain a blood glucose level of about 250 mg/ dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA. Fifty percent dextrose is used to treat hypoglycemia. Phenytoin (Dilantin) is not a usual treatment measure for DKA.

A nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited in the client, would indicate hyperglycemia and warrant physician notification?

1. Polyuria
2. Diaphoresis
3. Hypertension
4. Increased pulse rate

1. Polyuria
Rationale: Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

A nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The priority nursing diagnosis would be:

1. Deficient knowledge
2. Deficient fluid volume
3. Compromised family coping
4. Imbalanced nutrition, less than body requirements

2. Deficient fluid volume
Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the subject of the question.

A home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?

1. “I need to stop my insulin.”
2. “I need to increase my fluid intake.”
3. “I need to monitor my blood glucose every 3 to 4 hours.”
4. “I need to call the physician because of these symptoms.”

1. “I need to stop my insulin.”
Rationale: When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the physician. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones.

A nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to prepare to:

1. Correct the acidosis.
2. Administer 5% dextrose intravenously.
3. Administer regular insulin intravenously.
4. Apply a monitor for an electrocardiogram.

3. Administer regular insulin intravenously.
Rationale: Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (regular insulin), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not a priority action.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise?

1. “The best time for me to exercise is after I eat.”
2. “The best time for me to exercise is after breakfast.”
3. “The best time for me to exercise is mid- to late afternoon.”
4. “The best time for me to exercise is after my morning snack.”

3. “The best time for me to exercise is mid- to late afternoon.”
Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 1, 2, and 4 do not address peak action times.

A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/ dL , temperature of 101 ° F, pulse of 88 beats/ min, respirations of 22 breaths/ min, and blood pressure of 100/ 72 mm Hg. Which finding would be of most concern to the nurse?

1. Pulse
2. Respiration
3. Temperature
4. Blood pressure

3. Temperature
Rationale: An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.

A nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder?

1. “I take oral insulin instead of shots.”
2. “By taking these medications, I am able to eat more.”
3. “When I become ill, I need to increase the number of pills I take.”
4. “The medications I’m taking help release the insulin I already make.”

4. “The medications I’m taking help release the insulin I already make.”
Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia . Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating . On entering the client’s room, the nurse finds the client to be confused and diaphoretic. Which action is appropriate at this time?

1. Call a code to obtain needed assistance immediately.
2. Obtain a capillary blood glucose level and perform a focused assessment.
3. Stay with the client and ask the nursing assistant to call the physician for a prescription for intravenous 50% dextrose.
4. Ask the nursing assistant to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat.

2. Obtain a capillary blood glucose level and perform a focused assessment.
Rationale: Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client’s change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client’s condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the nursing assistant to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

A nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaint( s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

1. Tremors
2. Anorexia
3. Irritability
4. Nervousness
5. Hot, dry skin
6. Muscle cramps

1. Tremors
3. Irritability
4. Nervousness
Rationale: Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the signs of hypoglycemia.
Functions of the liver
produces bile
eliminates bilirubin
metabolizes hormones and drugs
metabolizes proteins, carbohydrates, & fats
synthesizes plasma proteins
synthesizes clotting factors
stores vitamins and minerals
Bilirubin
the end product of RBC breakdown
Plasma proteins
regulate fluid balance – plasma colloidal osmotic pressure
Hemolytic Jaundice
due to increased breakdown of RBCs – blood transfusion reactions, anemia
Hepatocellular Jaundice
Liver’s inability to take up bilirubin and excrete it – happens with hepatitis, cirrhosis, and hepatic carcinoma
Obstructive Jaundice
impaired flow of bile through the liver or biliary tract – occurs with hepatitis, cirrhosis, hepatic and pancreatic CA, and biliary stones
Preicteric Stage of Hepatitis
The first stage of hepatitis preceding the appearance of jaundice; includes flu-like symptoms
Assess for flu-like symptoms— malaise, fatigue
Anorexia, nausea, vomiting, diarrhea
Pain— headache, muscle aches, polyarthritis
Serum bilirubin and enzyme levels are elevated.
Icteric Stage of Hepatitis
The second stage of hepatitis; includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay -colored stools
Assess for jaundice, pruritus, dark or tea-colored urine, clay colored stools, and a decrease in preicteric-phase symptoms
Posticteric Stage of Hepatitis
The convalescent stage of hepatitis, in which the jaundice decreases and the color of the urine and stool return to normal
Assess for increased energy levels, subsiding of pain, minimal to absent gastrointestinal symptoms, and serum bilirubin and enzyme levels return to normal.
Population most at risk for Hepatitis A
Commonly seen in young children, individuals in institutionalized settings, and health care personnel.
Transmission of Hepatitis A
1. Fecal-oral route
2. Person-to-person contact
3. Parenteral
4. Contaminated fruits, vegetables, or uncooked shellfish
5. Contaminated water or milk
6. Poorly washed utensils
Treatment and Prevention of Hepatitis A
1. Strict handwashing
2. Stool precautions
3. Treatment of municipal water supplies
4. Serological screening of food handlers
5. Hepatitis A vaccine (Havrix VAQTA)
6. Immune globulin: For individuals exposed to HAV who have never received the hepatitis A vaccine; administer immune globulin during the period of incubation and within 2 weeks of exposure.
7. Immune globulin and hepatitis A vaccine are recommended for household members and sexual contacts of individuals with hepatitis A.
8. Preexposure prophylaxis with immunoglobulin is recommended to individuals traveling to countries with poor or uncertain sanitation conditions.
Populations at Risk for Hepatitis B
1. IV drug users
2. Clients undergoing long-term hemodialysis
3. Health care personnel
Modes of Transmission for Hepatitis B
1. Blood or body fluid contact
2. Infected blood products
3. Infected saliva or semen
4. Contaminated needles
5. Sexual contact
6. Parenteral
7. Perinatal period
8. Blood or body fluids contact at birth
Complications of Hepatitis B
1. Fulminant hepatitis
2. Chronic liver disease
3. Cirrhosis
4. Primary hepatocellular carcinoma
Prevention and Treatment for Hepatitis B
1. Strict handwashing
2. Screening blood donors
3. Testing of all pregnant women
4. Needle precautions
5. Avoiding intimate sexual contact if test for hepatitis B surface antigen (HBsAg) is positive.
6. Hepatitis B vaccine : Engerix-B (adult), Recombivax HB (pediatric); there is also an adult vaccine that protects against hepatitis A and B known as Twinrix.
7. Hepatitis B immune globulin is for individuals exposed to HBV through sexual contact or through the percutaneous or transmucosal routes who have never had hepatitis B and have never received hepatitis B vaccine.
Populations at Risk for Hepatitis C
1. Parenteral drug users
2. Clients receiving frequent transfusions
3. Health care personnel
Complications of Hepatitis C
1. Chronic liver disease
2. Cirrhosis
3. Primary hepatocellular carcinoma
Hepatitis D
coinfects with Hepatitis B – causes more severe disease and greater risk of fulminant hepatitis
Hepatitis E
transmitted by fecal-oral route by contaminated water – usually occurs in developing countries – full recovery is expected
Home Care for Hepatitis
Rest
No close contact
Avoid alcohol and hepatotoxic medications
Antiemetics – Tigan – no compazine
High carb, high protein, low fat diet – max intake at breakfast and small frequent feedings
Vitamin B complex and Vitamin K supplements
Fluids – 2,500 – 3,000 mL/day
Laënnec’s Cirrhosis
Cirrhosis is alcohol-induced, nutritional, or portal. Cellular necrosis causes eventual widespread scar tissue, with fibrotic infiltration of the liver.
Postnecrotic Cirrhosis
Cirrhosis occurs after massive liver necrosis. Cirrhosis results as a complication of hepatitis or exposure to hepatotoxins. Scar tissue causes destruction of liver lobules and entire lobes.
Biliary Cirrhosis
Cirrhosis develops from chronic biliary obstruction, bile stasis, and inflammation, resulting in severe obstructive jaundice.
Cardiac Cirrhosis
Cirrhosis is associated with severe, right-sided congestive heart failure and results in an enlarged, edematous, congested liver. The liver becomes anoxic, resulting in liver cell necrosis and fibrosis.
Complications of Cirrhosis
Portal hypertension
Ascites
Bleeding esophageal varices
Coagulation defects
Jaundice
Portal systemic encephalopathy
Hepatorenal syndrome
Cirrhosis and Portal Hypertension
A persistent increase in pressure in the portal vein that develops as a result of obstruction to flow – collateral circulation develops along esophagus, abdominal, and rectal areas.
Cirrhosis and Ascites
Accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries.
Capillary congestion leads to plasma leaking directly from the liver surface and portal vein.
Due to increased BP, increased osmotic pressure, decreased colloidal oncotic pressure, and hyperaldosteronism.
Cirrhosis and coagulation defects
Decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble vitamins.
Without vitamin K and clotting factors II, VII, IX, and X, the client is prone to bleeding.
Cirrhosis and jaundice
Occurs because the liver is unable to metabolize bilirubin and because the edema, fibrosis, and scarring of the hepatic bile ducts interfere with normal bile and bilirubin secretion
Portal systemic encephalopathy
End -stage hepatic failure characterized by altered level of consciousness, neurological symptoms, impaired thinking, and neuromuscular disturbances; caused by failure of the diseased liver to detoxify neurotoxic agents such as ammonia.
S&S: euphoria, depression, apathy, irritability, aggitation, slow/slurred speech, + babinski reflex, memory loss, disorientation, asterixis, fine motor impairment, apraxia, fector hepaticus
Hepatorenal syndrome
Progressive renal failure associated with hepatic failure characterized by a sudden decrease in urinary output, elevated blood urea nitrogen and creatinine levels, decreased urine sodium excretion, and increased urine osmolarity
Early Manifestations of Cirrhosis
RUQ pain
Anorexia
Dyspepsia
Flatulence
Change in bowel patterns
Fever
Weight loss
Fatigue
Enlarged liver/spleen
Later Manifestations of Cirrhosis
Jaundice
Skin lesions
Clotting defects
Gynecomastia
Loss of axillary and pubic hair
Impotence
Decreased libido
Sodium and water retention
Peripheral neuropathy
Hyperaldosteronism and cirrhosis
Aldosterone is not being metabolized by the liver and causes increased reabsorption of sodium and water retention, K+ loss – contributes to ascites
Asterixis
a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers
Apraxia
inability to construct simple figures
Factor hepaticus
sweet odor on breath
Interventions for Ascites
elevate HOB
I&O
daily weights and abdominal girth
sodium restriction – no beer, baking soda/powder, chips, canned goods, carbonation
administer k+ sparing diuretics
administer salt poor albumin
paracentesis (empty bladder)
salt poor albumin
used to treat ascites – increases colloidal oncotic pressure and maintains intravascular volume and urinary output
Surgical interventions for ascites
peritoneovenous shunt
La Veen/Denver shunt
for continuous reinfusion or ascitic fluid into the venous system
Medications used for Esophageal Varices
Vasopressin
Nitroglycerin
Beta blockers
Procedures used for management of esophageal varices
endoscopic sclerotherapy
esophageal balloon tamponade
portacaval shunt
TIPS – transjugular intrahepatic portosystemic shunt
Minnesota/Sengstaken Blakemore Tube
tubes used to create a balloon tamponade and compress esophageal varices to prevent bleeding
Interventions for Esophageal Balloon Tamponade
ensure inflation of 2 balloons used to secure tube
aspiration/irrigation port is used for saline lavage
balloon is deflated q 8-12 hours
semi-fowler’s position
label ports and attach to suction
monitor for airway obstruction – if obstruction then cut tube
Interventions of esophageal varices
1. Monitor vital signs.
2. Elevate the head of the bed.
3. Monitor for orthostatic hypotension.
4. Monitor lung sounds and for the presence of respiratory distress.
5. Administer oxygen as prescribed to prevent tissue hypoxia.
6. Monitor level of consciousness.
7. Maintain NPO status.
8. Administer fluids intravenously as prescribed to restore fluid volume and electrolyte imbalances; monitor intake and output.
9. Monitor hemoglobin and hematocrit values and coagulation factors.
10. Administer blood transfusions or clotting factors as prescribed.
11. Assist in inserting a nasogastric tube or a balloon tamponade as prescribed; balloon tamponade is not used frequently because it is very uncomfortable for the client and its use is associated with complications.
12. Prepare to assist with administering medications to induce vasoconstriction and reduce bleeding.
13. Instruct the client to avoid activities that will initiate vasovagal responses.
14. Prepare the client for endoscopic procedures or surgical procedures as prescribed.
TIPS
The nonsurgical procedure uses the normal vascular anatomy of the liver to create a shunt with the use of a metallic stent. The shunt is between the portal and systemic venous system in the liver and is aimed at relieving portal hypertension.
Endoscopy sclerotherapy
The procedure involves the injection of a sclerosing agent into and around bleeding varices. Complications include chest pain, pleural effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus.
Interventions for hepatic encephalopathy
goal: decrease ammonia levels
protein restriction
administer neomycin sulfate – reduces bacterial action of bowel proteins
administer lactulose – decreases colon pH producing acid, decreases bacterial growth and ammonia formation
administer levdopa – decreases dopamine and norepinephrine
Medications used to treat hepatic encephalopathy
Neomycin sulfate
Lactulose
Levdopa
Causes of Pancreatitis
alcohol abuse
biliary tract disease
infection
drugs (steroids, thiazide, diuretics, sulfonamides, NSAIDs)
trauma
metabolic disorders – hyperlipidemia, hyperparathyroidism, renal failure
Kaposi sarcoma
Diagnostic tests for pancreatitis
amylase
lipase
glucose
triglycerides
calcium
24hr urine (renal amylase and creatinine clearance)
ERCP
X-Ray/Ultrasound/CT
S&S pancreatitis
Abdominal pain, including a sudden onset at a midepigastric or left upper quadrant location with radiation to the back
Pain aggravated by a fatty meal, alcohol, or lying in a recumbent position – flexion of spine may relieve
Abdominal tenderness and guarding
Nausea and vomiting
Weight loss
Absent or decreased bowel sounds
Elevated white blood cell count, and glucose, bilirubin, alkaline phosphatase, and urinary amylase levels
Elevated serum lipase and amylase levels
Grey Turner Spots
associated with pancreatitis – bluish discoloration of the flanks. Both signs are indicative of pancreatitis.
Cullen’s sign
associated with pancreatitis – the discoloration of the abdomen and periumbilical area.
Complications of pancreatitis
hypovolemic shock
pseudocyst
abscess
pleural effusion
atelectasis
pneumonia
tetany
Interventions for pancreatitis
a. Maintain NPO status and maintain hydration with IV fluids as prescribed.
b. Administer parenteral nutrition for severe nutritional depletion.
c. Administer supplemental preparations and vitamins and minerals to increase caloric intake if prescribed.
d. Maintain nasogastric tube to decrease gastric distention and suppress pancreatic secretion.
e. Administer meperidine hydrochloride (Demerol) as prescribed for pain because it causes less incidence of smooth muscle spasm of the pancreatic ducts and sphincter of Oddi than some other medications.
f. Administer antacids as prescribed to neutralize gastric secretions.
g. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to decrease hydrochloric acid production and prevent activation of pancreatic enzymes.
h. Administer anticholinergics as prescribed to decrease vagal stimulation, decrease gastrointestinal motility, and inhibit pancreatic enzyme secretion.
i. Instruct the client in the importance of avoiding alcohol.
j. Instruct the client in the importance of follow-up visits with the physician.
k. Instruct the client to notify the physician if acute abdominal pain, jaundice, clay-colored stools, or dark-colored urine develops.
Surgical management for Pancreatitis
ERCP
percutaneous drainage of pseudocyst/abscess
Whipple procedure (cancer)
Diet for acute pancreatitis
NPO
TPN
eventually progress to small frequent feedings
high carb and protein, low fat
no stimulants ie. coffee, alcohol
supplement w/ fat soluble vitamins

The client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client’s pain. What type of pain is consistent with this diagnosis?

1. Burning and aching, located in the left lower quadrant and radiating to the hip
2. Severe and unrelenting, located in the epigastric area and radiating to the back
3. Burning and aching, located in the epigastric area and radiating to the umbilicus
4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin

2. Severe and unrelenting, located in the epigastric area and radiating to the back
Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?

1. Right lower quadrant, radiating to the back
2. Right lower quadrant, radiating to the umbilicus
3. Right upper quadrant, radiating to the left scapula and shoulder
4. Right upper quadrant, radiating to the right scapula and shoulder

4. Right upper quadrant, radiating to the right scapula and shoulder
During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder . This is determined by the pattern of dermatomes in the body. The other options are incorrect.

The client is admitted to the hospital with viral hepatitis, complaining of “no appetite” and “losing my taste for food.” What instruction should the nurse give the client to provide adequate nutrition?

1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only three large meals daily.

2. Increase intake of fluids, including juices.
Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet because fat may be tolerated poorly because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently , appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/ day that includes nutritional juices is also important.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following?

1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort

1. Malaise
Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort , and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client’s care plan?

1. Monitoring the temperature
2. Monitoring complaints of heartburn
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex

4. Assessing for the return of the gag reflex
The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client’s airway. The nurse also monitors the client’s vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client’s airway is the priority.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement?

1. “I know I must sign the consent form.”
2. “I hope the throat spray keeps me from gagging.”
3. “I’m glad I don’t have to lie still for this procedure.”
4. “I’m glad some IV medication will be given to relax me.”

3. “I’m glad I don’t have to lie still for this procedure.”
The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

The physician has determined that the client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?

1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D

1. Hepatitis A
Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate?

1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Notify the physician.
4. Document the findings.

4. Document the findings.
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/ day. The nurse would document the output.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, board-like abdomen

4. A rigid, board-like abdomen
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board -like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

The nurse is caring for a client following a Billroth II procedure. Which postoperative prescription should the nurse question and verify?

1. Leg exercises
2. Early ambulation
3. Irrigating the nasogastric tube
4. Coughing and deep-breathing exercises

3. Irrigating the nasogastric tube
In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the physician. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

1. Dorsiflex the client’s foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward.

3. Ask the client to extend the arms.
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down , wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect.

The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client?

1. Low-protein diet
2. High-protein diet
3. Moderate-fat diet
4. High-carbohydrate diet

1. Low-protein diet
Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom( s) of duodenal ulcer?

1. Weight loss
2. Nausea and vomiting
3. Pain relieved by food intake
4. Pain radiating down the right arm

3. Pain relieved by food intake
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or “hungry” pain that often localizes in the midepigastric area . The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.

A nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following interventions would the nurse expect to be prescribed for the client? Select all that apply.

1. Administer antacids as prescribed.
2. Encourage coughing and deep breathing.
3. Administer anticholinergics as prescribed.
4. Give small, frequent high-calorie feedings.
5. Maintain the client in a supine and flat position.
6. Give Meperidine (Demerol) as prescribed for pain.

1. Administer antacids as prescribed.
2. Encourage coughing and deep breathing.
3. Administer anticholinergics as prescribed.
6. Give Meperidine (Demerol) as prescribed for pain.
The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.
S&S of Cholecystitis
1. Nausea and vomiting
2. Indigestion
3. Belching
4. Flatulence
5. Epigastric pain that radiates to the scapula 2 to 4 hours after eating fatty foods and may persist for 4 to 6 hours
6. Pain localized in right upper quadrant
7. Guarding, rigidity, and rebound tenderness
8. Mass palpated in the right upper quadrant
9. Murphy’s sign ( cannot take a deep breath when the examiner’s fingers are passed below the hepatic margin because of pain)
10. Elevated temperature
11. Tachycardia
12. Signs of dehydration
Signs of biliary obstruction
1. Jaundice
2. Dark orange and foamy urine
3. Steatorrhea and clay-colored feces
4. Pruritus
Complications of cholecystitis
subphrenic abscess
pancreatitis
biliary cirrhosis
peritonitis from rupture of the gallbladder
bile duct obstruction
Interventions for cholecystitis
1. Maintain NPO status during nausea and vomiting episodes.
2. Maintain nasogastric decompression as prescribed for severe vomiting.
3. Administer antiemetics as prescribed for nausea and vomiting.
4. Administer analgesics as prescribed to relieve pain and reduce spasm.
5. Administer antispasmodics (anticholinergics ) as prescribed to relax smooth muscle.
6. Instruct the client with chronic cholecystitis to eat small, low-fat meals.
7. Instruct the client to avoid gas-forming foods.
8. Prepare the client for nonsurgical and surgical procedures as prescribed.
Non-surgical procedures for cholecystitis
ERCP – remove stones with stent placement
ESWL – shock waves used to disintegrate stones
Surgical procedures for cholecystitis
cholecystectomy
laparoscopic cholecystectomy
t-tube
t-tube care
connected to drain
blood tinged drainage changes to greenish/brown
may drain 500mL in first 24hrs
200mL drainage after 2-3 days
fowler’s position
when drainage subsides t tube can be clamped before and after meals
Post Op interventions after cholecystecomy
1. Monitor for respiratory complications caused by pain at the incisional site.
2. Encourage coughing and deep breathing.
3. Encourage early ambulation.
4. Instruct the client about splinting the abdomen to prevent discomfort during coughing.
5. Administer antiemetics as prescribed for nausea and vomiting.
6. Administer analgesics as prescribed for pain relief.
7. Maintain NPO status and nasogastric tube suction as prescribed.
8. Advance diet from clear liquids to solids when prescribed and as tolerated by the client.
9. Maintain and monitor drainage from the T-tube, if present
t-tube
A T-tube is placed after surgical exploration of the common bile duct. The tube preserves the patency of the duct and ensures drainage of bile until edema resolves and bile is effectively draining into the duodenum. A gravity drainage bag is attached to the T-tube to collect the drainage.

“1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what “”type 2″” means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with …

A client asks the nurse why the provider bases his medication regimen on his HbA1C instead of his log of morning fasting blood glucose results. Which of the following is an appropriate response by the nurse? A. HB A1C measures …

A client’s fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first? a) Give the prescribed dose of insulin. b) Give one ampule of 50% dextrose via …

1. When formulating a definition of “health,” the nurse should consider that health, within its current definition, is: 1. The absence of disease 2. A function of the physiological state 3. The ability to pursue activities of daily living 4. …

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