ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 45 : Caring for Clients With Disorders of the Upper Gastrointestinal Tract Questions
Question 1 of 5
A nurse is providing discharge teaching for a client following Roux-En-Y (RYGB) surgery. What instruction(s) should the nurse include in the teaching? Select all that apply.
Correct Answer: A,B,C
Rationale: The nurse should instruct the client to stop eating when the client feels full, avoid all sweets, and choose breads, cereals, and grains that provide less than 2 g of fiber per serving. The client should plan to take an hour to eat, chewing food slowly and thoroughly. The client should not begin with five to six meals a day but should instead gradually progress to this number of meals.
Question 2 of 5
The nurse is caring for a client with anorexia and constipation due to reduced bulk in the diet and the use of liquid supplements. Which intervention(s) should the nurse include in the plan of care for the client? Select all that apply.
Correct Answer: A,B,C,D
Rationale: The nurse should keep a record of the client's bowel movements, consult with the health care provider and dietitian about changing the type of supplement, dilute the formula until the client adjusts to the concentrated contents, and administer a prescribed stool softener. Dietary fiber should be increased, not decreased, as a decrease will further reduce the amount of bulk in the client's diet and contribute to further constipation.
Question 3 of 5
The nurse is preparing to administer ondansetron to an older adult client. Which safety warning(s) should the nurse consider when administering the medication? Select all that apply.
Correct Answer: A,B,C
Rationale: When administering ondansetron to an older adult client, the nurse should take extra care to consider safety warnings that advise the nurse to avoid use if a client has a heart block or prolonged QT interval, and should also be mindful that the medication can increase sedation when used with opiates. In addition, the nurse should adhere to guidelines instructing an emphasis on prevention for the client, the older adult client must take the medication consistently to prevent nausea and vomiting. Ondansetron is not given to relieve motion sickness; therefore, beginning the medication before travel is not applicable. Prochlorperazine, not ondansetron, may increase dehydration in older adults.
Question 4 of 5
The nurse is caring for a client with hypovolemia related to prolonged vomiting and decreased intake of oral fluids. What activity(ies) should the nurse include in the client's plan of care? Select all that apply.
Correct Answer: D,E
Rationale: The nurse should monitor the client's weight daily and assess skin turgor and mucous membranes. The nurse should offer clear liquids in small amounts. Slow introduction of fluids enables the client to develop tolerance and determine if it is possible to advance the diet. The nurse should recommend the use of commercial, over-the-counter beverages that contain electrolytes. If the client's urine output drops below 17 oz (500 mL) per day, the nurse should notify the primary provider because this indicates severe dehydration and the need for IV replacement fluids.
Question 5 of 5
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
Correct Answer: A,B
Rationale: The nurse should inform the client that oral cancer is characteristically asymptomatic in its early stage, though lesions, lumps, or other abnormalities may be present on the lips and mouth. While it is true that oral cancer may cause difficulty eating or tasting food, pain and numbness, and persistent hoarseness, these events occur later in the disease's progression and are not relevant in discussion of the early stage.