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A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?
- A. Ask the client about recent exposure to illness.
- B. Collect the stool sample for the client.
- C. Include the date and time on the specimen container.
- D. Don gloves prior to collecting the sample.
Correct Answer: D
Rationale: To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.
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A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
- A. Is a good thing I love oranges and cherry gelatin.
- B. My spouse will be here to drive me home.
- C. I should refrigerate the Gol/TELY before use.
- D. I will buy a case of Gonoxide before the prop.
Correct Answer: A
Rationale: The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
The student nurse studying the gastrointestinal system understands that chyme refers to what?
- A. Hormenization that reduces acidity.
- B. Liquedied food ready for digestion
- C. Nutrients after being absorbed
- D. Secretions that help digest food
Correct Answer: B
Rationale: Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out so the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake into individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
- A. Colon cancer
- B. Diverticulitis
- C. Inflammatory bowel disease
- D. Peptic ulcer disease
- E. Pernicious anemia
Correct Answer: A,B,C,D
Rationale: In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
- A. Auscultate the abdomen.
- B. Notify the provider immediately.
- C. Order an abdominal flat-plate x-ray.
- D. Palpate the abdomen to assess size.
Correct Answer: B
Rationale: The observation could indicate an abdominal aortic aneurysm, which could be life-threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated, but it is not the priority. Auscultation is part of the assessment, but the nurse's priority action is to notify the provider.
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best?
- A. Ask the client about difficult allergies.
- B. Document this information on the chart.
- C. Insureat that the client has a ride home.
- D. Insureat that the client has a ride home.
Correct Answer: A
Rationale: PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish, as these may indicate a risk for iodine allergy. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done as an outpatient, but this is not the priority action.