NCLEX - GI Day1 (Part 2)

The nurse is caring for a client recently diagnosed with a hiatal hernia. Which of the following actions should the nurse take? Select all that apply.

• Elevate the head of the bed at least 30 degrees
• Encourage use of compression garments around the abdomen
• Instruct the client to avoid caffeinated beverages
• Offer small, frequent, low-fat meals
• Tell the client to avoid lifting and straining

Answer explanation

Conditions that increase intraabdominal pressure (IAP) (eg, pregnancy, obesity, ascites, tumors) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. Although hiatal hernias can be asymptomatic, many clients experience signs and symptoms of gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain. To help clients reduce the risk for herniation and associated symptoms, the nurse should instruct the client to: Elevate the head of the bed to maintain an upright position and encourage esophageal emptying (Option 1). Avoid foods and beverages that decrease pressure of the lower esophageal sphincter (eg, chocolate, peppermint, tomatoes, caffeine); decreased pressure allows reflux of gastric contents into the esophagus (Option 3). Eat a low-fat diet consisting of small, frequent meals (Option 4). The client also should decrease fluid intake during meals (to prevent gastric distension) and avoid eating close to bedtime and during the night. Avoid lifting and straining. These actions increase IAP, make the hernia larger, and make GERD symptoms worse (Option 5). Quit smoking and reduce weight, if appropriate. (Option 2) Loose, nonrestrictive clothing should be encouraged. Tight clothing around the waist increases IAP.

The nurse is caring for a client who is receiving enteral feedings after sustaining severe burns to the face. Which of the following statements by the nurse would indicate a correct understanding of why the client is receiving enteral feedings instead of parenteral nutrition?

• Enteral feedings help maintain gut integrity and prevent stress ulcers.
• Hyperglycemia occurs with parenteral nutrition but not with enteral feedings.
• Enteral feedings can be used for extended durations, and parenteral nutrition cannot.
• There is higher calorie and nutrient content in enteral feedings than in parenteral nutrition.
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Answer explanation

Stress ulcers (ie, Curling ulcers) of the gastrointestinal tract are a common complication in clients who are critically ill (eg, sepsis, shock, burns). Decreased perfusion causes blood to be shunted away from the gut to the more vital organs, increasing the risk for stress ulcers. Clients with a functional gastrointestinal tract are candidates for enteral nutrition. Enteral feedings (eg, nasogastric tube, percutaneous endoscopic gastrostomy tube) help preserve gut integrity, limit movement of bacteria from the intestines into the bloodstream, and prevent stress ulcers (Option 1). (Option 2) Hyperglycemia can occur with both enteral feedings and parenteral nutrition if the carbohydrate content of the formula is too high. Illness-related stress hyperglycemia (gluconeogenesis) can also occur with both enteral feedings and parenteral nutrition. (Option 3) Nasal and oral tubes used for enteral nutrition may remain in place for approximately 4 weeks prior to surgical placement of gastrostomy and jejunostomy tubes, which can be used for an extended time. Parenteral nutrition may also be administered long term via a central venous access device. (Option 4) Caloric and metabolic needs can usually be met adequately with enteral feedings or parenteral nutrition. Multiple enteral and parenteral formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, parenteral nutrition can be added.

The nurse is planning care for a client who had a hemorrhoidectomy. Which of the following interventions should the nurse include in the client's plan of care?

• Administer stool softeners and pain medications to the client.
• Remind the client to avoid straining during defecation.
• Encourage the client to increase the daily fluid intake.
• Teach the client how to self-administer a sitz bath.
• Provide the client with a list of low-fiber foods.

Answer explanation

Hemorrhoids are distended, inflamed veins located in the anus or lower rectum caused by increased anorectal pressure (eg, straining to defecate, constipation). Surgical removal of hemorrhoids (ie, hemorrhoidectomy) is generally indicated for severe, recurring hemorrhoids that do not respond to conservative treatments (eg, topical hydrocortisone, sitz baths). Management for clients after hemorrhoidectomy includes: Preventing constipation: Stool softeners (eg, docusate) and increased fluid intake can help facilitate regular bowel movements. The client should avoid straining during defecation, which increases the risk for pain, bleeding, and a vasovagal response (eg, syncope) (Options 1, 2, and 3). Providing pain relief: The pain associated with hemorrhoidectomy is severe due to spasms of the anal sphincter. Pain is typically managed with NSAIDs (eg, ibuprofen) and/or acetaminophen; opioids may be prescribed but can worsen constipation. Warm sitz baths are used beginning 1-2 days postoperatively to provide pain relief and decrease swelling (Option 4). (Option 5) Clients should consume a diet high in fiber to facilitate regular bowel movements.

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome?

• Meals should be small and low in carbohydrate content
• Fluids should be encouraged with each meal
• Take a multivitamin with iron and calcium supplements daily
• You will need to take your cobalamin injection monthly
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Answer explanation

An RYGB procedure uses a small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as nausea, vomiting, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids (Option 1). (Option 2) Clients should be taught to consume food and fluids at least 30 minutes apart, and the health care provider may limit total daily fluid consumption. Limiting fluids decreases distension and feelings of fullness. (Option 3) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome. (Option 4) The smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, which may cause cobalamin deficiency. The client will need parenteral or intranasal cobalamin replacement; however, this will not prevent dumping syndrome.

The nurse is caring for a client who had a gastrojejunostomy and is reporting episodes of nausea, dizziness, and sweating that occur shortly after eating. Which of the following actions should the nurse take?

• Encourage the client to increase the consumption of carbohydrates
• Check the client's blood pressure while lying down and standing
• Recommend that the client consume extra fluids with meals
• Instruct the client to recline for a short time after meals
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Answer explanation

Gastrojejunostomy (ie, Billroth II procedure) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when rapid gastric emptying causes a fluid shift into the small intestine. Symptoms include dizziness, sweating, nausea, abdominal cramping, tachycardia, and diarrhea shortly after meal consumption. To reduce the occurrence of symptoms, clients should recline after eating meals to slow the emptying of gastric contents. An upright or seated position increases the force of gravity, which increases the rate of gastric emptying (Option 4). (Options 1 and 3) Simple carbohydrates (eg, candy) and fluid consumption with meals cause stomach contents to pass faster into the jejunum and worsen symptoms. The client should instead follow a high-protein, high-fiber diet with small amounts of complex carbohydrates (eg, beans, whole grains) and consume fluids at least 30 minutes before or after meals rather than with meals. (Option 2) Reports of dizziness after standing may indicate orthostatic hypotension and warrant assessment of blood pressure while lying and standing; however, dizziness after eating is indicative of dumping syndrome.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client?

• Encourage client to eat bulk-forming foods such as whole grain bread
• Encourage rest, fluids, and acetaminophen for the fever
• Make an appointment for the client with the health care provider today
• Take 2 tablets of loperamide followed by 1 tablet after each loose stool
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Answer explanation

Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile). (Option 1) Instructions on eating bulk-forming foods may be helpful with diarrhea; however, this option does not seek to address the underlying problem causing the 4 days of diarrhea and fever. The client should see the HCP. (Option 2) Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring ≤48 hours without other symptoms. (Option 4) Loperamide (Imodium) is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used more than 2 days or if fever is present as retention of bacteria or toxins inside the colon can make the process worse and cause toxic megacolon.

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? Select all that apply.

• Avoid social gatherings that occur in restaurants or around meals
• Create multiple small goals with rewards for achievement
• Identify a list of desired outcomes not directly related to weight loss
• Perform anxiety-reducing activities rather than using food to cope with stress
• Utilize visual cues such as motivational quotes to encourage positive behavior

Answer explanation

Obesity is a health alteration that may be caused by multiple factors (eg, genetics, diet, pathology, lifestyle choices). Diet and exercise modifications are the main components of weight reduction. However, clients with obesity may also require education and assistance with psychosocial aspects and behavioral modification. Behavioral management includes: • Creating a reward system with many small, attainable goals to incentivize positive health behaviors (Option 2) • Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight (Option 3) • Adopting anxiety-reducing diversional activities (eg, reading, meditating, listening to music) as coping mechanisms to reduce stress eating (Option 4) • Placing visual cues (eg, motivational quotes) throughout the environment as positive reinforcement (Option 5) (Option 1) Avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal.

The nurse is talking with a client with peptic ulcer disease. Which of the following statements by the client would require immediate follow-up?

• I was nauseous and vomited a small amount after lunch today.
• After eating, I have pain in the middle of my upper abdomen.
• For the past few days, I have felt dizzy when I stand up.
• I feel very full and belch often after eating meals.
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Answer explanation

Peptic ulcer disease (PUD) occurs when the protective layers (ie, mucosa) of the esophagus, stomach, and/or duodenum become ulcerated. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, potentially leading to gastrointestinal bleeding (GIB) and perforation. GIB may occur as an acute hemorrhage with overt signs (eg, melena, hematemesis) or a slow, relatively undetectable bleed (ie, occult bleeding). Either type of GIB may be life-threatening without appropriate intervention. Clients with GIB often present initially with nonspecific symptoms including fatigue, activity intolerance, and pallor. As anemia from GIB worsens, clients may develop tachycardia, hypotension, and dizziness with position changes. Symptoms of GIB require immediate follow-up (Option 3). (Options 1, 2, and 4) Epigastric fullness, early satiety, increased belching, nausea/vomiting, and epigastric pain after meals are common, expected findings in clients with PUD. Severity of these symptoms should lessen with treatment, and further assessment may be safely delayed.

The nurse is caring for a client with acute pancreatitis who has severe nausea, frequent vomiting, epigastric pain, and tachycardia. Which of the following interventions should the nurse anticipate for this client? Select all that apply.

• Administer IV fluids
• Administer IV hydromorphone for pain
• Insert a nasogastric tube for nasogastric suction
• Maintain the client in a supine position with the head of bed flat
• Provide small, frequent, high-carbohydrate, high-calorie meals

Answer explanation

Acute pancreatitis is inflammation and autodigestion of pancreatic tissue that occurs from activation of pancreatic enzymes within the pancreas. Severe abdominal pain, especially after eating, is the primary clinical manifestation and is typically accompanied by nausea, vomiting, tachycardia, and jaundice. Management of acute pancreatitis includes: • Maintaining NPO status to inhibit stimulation of the pancreas and the excretion of pancreatic enzymes • Administering IV fluids to prevent hypovolemic shock; inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (ie, fluid entering empty spaces) (Option 1) • Administering IV opioid analgesics (eg, hydromorphone, fentanyl) to manage pain (Option 2) • Inserting a nasogastric tube to suction gastric secretions; this reduces nausea and lessens stimulation of the pancreas (Option 3) (Option 4) To relieve pain, the client should maintain a position that flexes the trunk and draw the knees up to the abdomen, decreasing tension on the abdomen. A side-lying position with the head elevated to 45 degrees will also help relieve pain. (Option 5) Clients should be kept NPO to prevent pain, nausea, and/or vomiting due to stimulation of pancreatic enzymes.

The nurse is talking with clients at a community health fair about the importance of dietary fiber. Which of the following should the nurse include as a benefit of a high-fiber diet? Select all that apply.

• regulates bowel movements
• improves serum glucose control
• decreases the risk for colorectal cancer
• increases the feeling of fullness when eating
• prevents exacerbations of systemic lupus erythematosus

Answer explanation

Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet with foods high in fiber (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps regulate bowel movements (eg, prevent constipation) and decreases the risk for colorectal cancer (Options 1 and 3). High-fiber foods tend to have a low glycemic load (less sugar per serving); they are nutrient dense yet have lower caloric density. Clients may experience increased satiety (ie, feeling of fullness) and decreased hunger because fiber absorbs water. This feeling of fullness may help reduce calorie intake, improve serum glucose control, and promote weight loss (Options 2 and 4). (Option 5) Systemic lupus erythematosus (SLE) is a chronic autoimmune condition that causes widespread inflammation in the body (eg, skin, joints, muscles) with exacerbations and periods of remission. Dietary fiber does not prevent exacerbations of SLE.