NCLEX Review about Digestive System Disorders 46-50

NCLEX Review about Digestive System Disorders

46. A client has Sengstaken-Blakemore tube. The nurse, during change-of-shift report should remind the next shift nurse to:

a) keep scissors at bedside
b) avoid instilling fluid into the aspiration port
c) keep tracheostomy tray at bedside
d) deflate the balloon for 15 to 30 minutes every 2 hours

47. The nurse is developing the plan of care for a client receiving continuous ambulatory peritoneal dialysis (CAPD). Which is the priority complication of CAPD to be addressed in the plan of care?

a) bleeding
b) pain
c) outflow problems
d) infection

Situation: Bobby, a 13 year old is being seen in the emergency room for possible appendicitis.

48. An important nursing action to perform when preparing Bobby for an appendectomy is to:

a) administer saline enemas to cleanse the bowels
b) apply heat to reduce pain
c) measure abdominal girth
d) continuously monitor pain

49. Which of the following would indicate that Bobby's appendix has ruptured?

a) diaphoresis
b) anorexia
c) pain at Mc Burney's point
d) relief from pain

50. A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by:

a) administering Tylenol (acetaminophen) for the elevated temperature
b) advising the client to increase oral fluids
c) asking the client when she last had a bowel movement
d) notifying the physician




NCLEX REVIEW ABOUT DIGESTIVE SYSTEM DISORDERS:
ANSWERS AND RATIONALE

46) A

- the nurse should keep scissors readily available at bedside for a client with Sengstaken-Blakemore tube. The scissors will be used to cut the tube in case of airway obstruction due to rupture of the gastric balloon and the esophageal balloon goes up into the pharynx.

47) D

- the most common complication of CAPD is infection (peritonitis). This should be given highest priroty when planning the care of the patient undergoing CAPD.

48) D
- Appendicitis is inflammation of the vermiform appendix (4 inches long) which may lead to edema, necrosis, abscess and rupture, and peritonitis. It is common among teenagers and young adults between 10-30 years old. Higher incidence is observed among males and in societies with diet low in fiber and high in refined carbohydrates.

Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation.

• Initially, appendicitis is manifested by acute and generalized pain of the abdomen that comes in waves.
• During the following 4 hours, pain intensifies and localizes at the right lower quadrant pain at the Mc Burney's point between the anterior iliac crest and umbilicus.
• The pain is aggravated by walking, moving and coughing
• Rebound tenderness (relief of pain on palpation and sudden pain on release of pressure) occurs with abdominal rigidity causing the patient to guard the abdomen.
• Patient tends to lie on back or side with knees bent to relieve pain as extension or internal rotation of the hip increases pain.

Other manifestations of appendicitis include:

• Anorexia, nausea and vomiting
• Chills and fever
• Leukocytosis - 10,000
• elevated neutrophils count

To prevent bowel perforation, it is important to avoid:

• enemas
• laxatives
• applying heat over the abdomen
• food and fluids per orem

49) D

50) D
- the patient's manifestations indicate rupture of the appendix and peritonitis.






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