The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?
I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. For the client’s comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to aid in the diagnosis of bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication often is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.
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?
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.
What laboratory finding is the primary diagnostic indicator for pancreatitis?
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.
To prevent gastroesophageal reflux in a male client with hiatal hernia, the nurse should provide which discharge instruction?
To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren’t gastric irritants.
A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
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.
When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.
A female client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Dysphagia isn’t associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
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 male 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?
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 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:
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.
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