NCLEX - GI Day2 (Part 2)

The nurse is caring for a client with end-stage liver disease who is being considered for a liver transplant. The client's spouse states that the client continues to drink alcohol and may be unable to stop. Which of the following actions would be most appropriate for the nurse to take?

• Request a referral for palliative care for the client.
• Assess the client's motivation to implement lifestyle changes.
• Notify the nurse manager that the client may not be an eligible candidate for transplant.
• Encourage the client's family members to assist the client in abstaining from alcohol before the transplant.
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Answer explanation

Liver transplantation is a surgical procedure in which the client's diseased liver is removed and replaced with healthy donor tissue. Transplantation requires certain lifelong self-care regimens (eg, immunosuppressant medications, complete abstinence from alcohol). The nurse should assess the client's drinking habits, motivation to stop drinking alcohol, and ability to implement the necessary lifestyle changes (eg, abstinence from alcohol) by speaking directly to the client (Option 2). The information obtained from this assessment should be communicated to the interdisciplinary team members responsible for determining transplant eligibility. (Option 1) Palliative care specialists can assist with identifying goals of care and facilitating decision-making for clients with end-stage liver disease. However, this does not address the concerns of the client's spouse. (Option 3) If the nurse is concerned about transplant eligibility, the concern should be communicated to the interdisciplinary team after further assessment. However, this should be done after discussing concerns with the client and spouse. (Option 4) Clients receiving a live transplant must remain sober for the remainder of the client's life, not just before the transplant. In addition, the nurse should first assess the client's motivation to stop drinking before the transplant and identify additional support for the client (eg, family members).

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed?

• I need to raise the head of my bed on blocks by at least 6 inches.
• I will remain sitting up for several hours after I eat any food.
• If my reflux and abdominal pain don't improve, I might need surgery.
• Losing weight may reduce my reflux, so I plan to take a weight-lifting class.
• -

Answer explanation

Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement.

A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply.

• Fruit juice is a good substitute for soda.
• I will aim to lose 1-2 lb (0.45-0.91 kg) per week.
• I will keep healthy snacks on hand in case I get hungry.
• I will skip breakfast to save calories for later in the day.
• I will take the stairs instead of the elevator.

Answer explanation

Clients aiming to achieve a healthy weight must take a multifaceted approach to eating and implement lifestyle changes. The nurse can assist clients with these changes by helping them form realistic and consistent modifications. Effective strategies include: · Eliminating sugar-containing beverages (eg, soda, juice, alcohol) to decrease non-nutritive caloric intake · Setting realistic goals to maintain motivation and prevent frustration and abandoned efforts; 1-2 lb (0.45-0.91 kg) per week is a healthy, realistic goal (Option 2). · Planning healthy meals and keeping nutritious snacks readily available to decrease likelihood of poor dietary choices (eg, fast food, vending machines) (Option 3) · Eating small, frequent meals to decrease hunger and tendency to overeat · Exercising about 30-60 minutes daily to promote weight reduction. Even small changes (eg, parking further away, using stairs instead of the elevator) can have long-term benefits (Option 5). · Getting adequate sleep (usually about 7-9 hours/night); sleep deprivation is associated with weight gain and obesity. (Option 1) Juice contains high amounts of natural sugar and is not an appropriate alternative for soda. (Option 4) Skipping meals for caloric reduction has been shown to increase the tendency to overeat at subsequent meals.

The nurse prepares to assess a newly admitted client with alcohol use disorder whose laboratory report shows a decreased magnesium level. Which assessment finding does the nurse anticipate?

• constipation and polyuria
• increased thirst and dry mucous membranes
• leg weakness and soft, flaccid muscles
• tremors and brisk deep-tendon reflexes
• -

Answer explanation

Hypomagnesemia, a low blood magnesium level (normal 1.3-2.1 mEq/L [0.65-1.05 mmol/L]), is associated with alcohol use disorder due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: 1. Ventricular dysrhythmias (eg, torsades de pointes): This is the most serious concern (priority). 2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option 2) Increased thirst with dry mucous membranes indicates hypernatremia. (Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flaccid muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias.

The nurse is assessing a client with suspected acute pancreatitis. Which of the following findings would support the diagnosis of acute pancreatitis?

• chest pain radiating to the right shoulder
• left flank pain radiating to the groin area
• left upper quadrant pain radiating to the back
• periumbilical pain radiating to the right lower quadrant
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Answer explanation

Due to alterations in taste perception, clients receiving chemotherapy often report a metallic taste in the mouth while eating. To overcome this, the nurse should encourage the client to: · Use plastic utensils · Avoid consuming red meat · Cold foods should be served These strategies help mask the metallic taste, improve food tolerance, and enhance nutrition. (Option 1) Eating eggs and poultry can help maintain adequate protein intake without exacerbating the taste problem. (Option 2) Offering liquids between bites may help cleanse the palate, but is less effective than altering utensils and food temperature. (Option 4) Avoiding very sweet or spicy food may help with general nausea but does not specifically target the metallic taste issue.

The nurse is teaching a client with cirrhosis who has portal hypertension and esophageal varices. Which of the following statements by the client would indicate a correct understanding of the teaching?

• I may have one alcoholic drink a day.
• I may take aspirin instead of acetaminophen for fever or pain.
• I should follow a low-protein diet.
• I should avoid straining while having a bowel movement.
• -

Answer explanation

The nurse should perform detailed medication reconciliation before administering medications. When a client states they’ve already taken their medication, the nurse must verify the timing, dosage, and reason before proceeding. If verified, the nurse should document and withhold the dose. (Option 2) Administering a second dose without verification could result in overdose. (Option 3) Involving a pharmacist is appropriate if discrepancies remain after investigation. (Option 4) Asking a supervisor may be necessary if there is concern about the nurse’s authority to withhold, but verification comes first.

During the immediate postoperative period after a colostomy, which stoma assessment requires the nurse to contact the health care provider immediately?

• Brick red with slight moisture
• Dusky with moderate edema
• Pink with slight oozing of blood
• Red with no stool produced
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Answer explanation

Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterized by sudden, progressive pulmonary edema and increasing bilateral lung infiltrates on chest x-ray. The priority treatment goal is ensuring adequate oxygenation. Mechanical ventilation with high oxygen concentrations is often required. The nurse should monitor oxygen saturation closely and report any decline. (Option 1) Checking for decreased breath sounds helps assess complications (eg, pneumothorax), but is not the priority. (Option 2) Monitoring ABGs helps gauge the severity of respiratory failure but does not treat the condition. (Option 4) Administering sedation or analgesics supports comfort and synchrony with ventilation but is secondary to oxygenation.

The nurse enters the room of a client who had major abdominal surgery 1 week ago and notes dehiscence and evisceration of the surgical incision. The nurse should immediately place the client in the

• low Fowler position with the knees bent
• prone position
• supine position with the head of the bed flat
• side-lying position
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Answer explanation

A client with Parkinson disease is at risk for falls due to motor symptoms such as bradykinesia, muscle rigidity, and postural instability. The nurse should implement fall precautions immediately. Interventions include: · Having client wear rubber-soled shoes · Removing rugs and clutter · Using assistive devices (eg, walker) · Encouraging an upright posture and use of furniture for support (Option 1) Fall risk is high with Parkinson disease regardless of current fall history. Prevention should be proactive. (Option 2) Asking the client to remain in bed limits mobility and independence. (Option 4) The nurse should not wait for a physical therapist assessment before initiating basic fall precautions.

The nurse is caring for a client who reports experiencing a burning sensation in the upper abdomen after eating for the past 3 months. The nurse should expect that the client will be prescribed

• rabeprazole
• ondansetron
• ademetionine
• promethazine
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Answer explanation

Preschool children often engage in imaginative play and may use toys or games to express emotions and understand the world. The nurse should encourage therapeutic play to help the child cope with hospitalization. For example, using a doll to demonstrate procedures allows the child to feel more in control and less fearful. (Option 1) Giving choices within limits supports autonomy but doesn’t provide emotional processing. (Option 2) Distraction techniques (eg, videos) can reduce distress but don’t facilitate understanding or emotional expression. (Option 4) Rewarding behavior reinforces compliance but isn’t emotionally therapeutic.

During assessment of a client with cholelithiasis and acute cholecystitis, which of the following findings should the nurse expect during the health history and physical examination? Select all that apply.

• Flank pain radiating to the groin
• High-protein food ingestion before the onset of pain
• Low-grade fever with chills
• Pain at the umbilicus
• Right upper quadrant pain radiating to the right shoulder

Answer explanation

To reduce aspiration risk in clients with dysphagia, the nurse should implement several precautions: · Place client in upright position during meals · Provide small bites and sips · Encourage slow eating and thorough chewing · Avoid distractions during meals · Keep the client sitting up for at least 30–40 minutes after eating These strategies support safe swallowing and prevent complications. (Option 1) Thickeners may help, but posture and pace are more immediately impactful. (Option 2) Tube feeding is only used when oral intake is not safe. (Option 3) Checking gag reflex is useful during assessment but not a feeding strategy.