The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
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Solution
Document the findings
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns to green-brown. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 ml per day. The nurse would document the output.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?
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Solution
Indomethacin (Indocin)
Indomethacin (Indocin) is a NSAID and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a client with GI disorders.
The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?
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Solution
Vitamin B12
Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the functioning parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
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Solution
“It is best for me to take my antacid 1 to 3 hours after meals.”
Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug’s action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids.
A client has been taking aluminum hydroxide 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?
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Solution
The client is experiencing a side effect of the aluminum hydroxide.
It is most likely that the client is experiencing a side effect of the antacid. Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in the body. These precipitate and accumulate in the intestines, causing constipation. Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the client but is not likely to relieve constipation caused by the aluminum hydroxide. Constipation, in isolation from other symptoms, is not a sign of bowel obstruction.
A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?
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Solution
At bedtime
Ranitidine blocks secretion of hydrochloric acid. Clients who take only one daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion of acid. Clients who take the drug twice a day are advised to take it in the morning and at bedtime.
While caring for a client with peptic ulcer disease, the client reports that he has been nauseated most of the day and is now feeling lightheaded and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? Select all that apply.
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Solution
Answers: 2 and 3.
The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client’s vital signs and notify the physician of the client’s symptoms. To administer an antacid hourly or to wait one hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.
A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?
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Solution
Disturbed Sleep Pattern related to epigastric pain
Based on the data provided, the most appropriate nursing diagnosis would be Disturbed Sleep pattern. A client with a duodenal ulcer commonly awakens at night with pain. The client’s feelings of anxiety do not necessarily indicate that she is coping ineffectively.
A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?
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Solution
Deficient knowledge related to unfamiliarity with significant signs and symptoms
Black, tarry stools are an important warning sign of bleeding in peptic ulcer disease. Digested blood in the stomach causes it to be black. The odor of the stool is very stinky. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their physician.
The nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.
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Solution
Answers: 2, 4, and 5.
Following a gastroscopy, the nurse should monitor the client for complications, which include perforation and the potential for aspiration. An elevated temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all indications of a possible perforation and should be reported promptly. A sore throat is a common occurrence following a gastroscopy. Clients are usually sedated to decrease anxiety and the nurse would anticipate that the client will be drowsy following the procedure.