Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet, which food should be included in the diet?
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Solution
Dark green, leafy vegetables
Dark green, leafy vegetables are rich in calcium.
Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?
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Solution
Restrict fluids
Restricting fluids decrease the amount of body fluid and the accumulation of fluid in the peritoneal space.
Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?
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Solution
Brownish-black stoma
A brownish-black color indicates lack of blood flow, and maybe necrosis.
Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial gastrectomy. Postoperative nursing care includes:
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Solution
Keeping her NPO until the return of peristalsis.
After surgery, she remains NPO until peristaltic activity returns. This decreases the risk for abdominal distention and obstruction.
Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?
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Solution
Glucose
Glucose level increases and diabetes mellitus may result d/t the pancreatic damage to the islets of Langerhans.
Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?
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Solution
Stools are less fatty and decreased in frequency.
Pancrelipase provides the exocrine pancreatic enzyme necessary for proper protein, fat, and carb digestion. With increased fat digestion and absorption, stools become less frequent and normal in appearance.
Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?
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Solution
Lower the height of the enema container.
Lowering the height decreases the amount of flow, allowing him to tolerate more fluid.
You’re patient is complaining of abdominal pain during assessment. What is your priority?
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Solution
Observe the contour of the abdomen.
The first step in assessing the abdomen is to observe its shape and contour, then auscultate, palpate, and then percuss.
Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient?
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Solution
NG feeding
Because the GI tract is functioning, feeding methods involve the enteral route which bypasses the mouth but allows for a major portion of the GI tract to be used.
Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
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Solution
Measure abdominal girth.
Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention.