124 Medsurg Exam 3; Gastrointestinal, Brunner Chapters 43,44,45,46,47

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient? A) "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." B) "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." C) "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." D) "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."

Ans: A) "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food" Feedback: The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment.

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? A) "Your appendix doesn't play a major role, so you won't notice any difference after you recovery from surgery." B) "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." C) "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." D) "Your large intestine will adapt over time to the absence of your appendix."

Ans: A) "Your appendix doesn't play a major role, so you wont notice any difference after you recover from surgery" Feedback: The appendix is an appendage of the cecum (not the large intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient? A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B) Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C) Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D) Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

Ans: A) Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN Feedback: After administration of the PN solution is gradually discontinued, an isotonic dextrose solution is administered for 1 to 2 hours to protect against rebound hypoglycemia. The other listed actions would likely cause hyperglycemia.

The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient? A) Avoid applying suction on or near the suture line. B) Position patient on the non operative side with the head of the bed down. C) Assess the patients ability to perform self-suctioning. D) Evaluate the patients ability to swallow saliva and clear fluids.

Ans: A) Avoid applying suction on or near the suture line Feedback: The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Self-sectioning may be unsafe because the patient may damage the suture line. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patients ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patients need for suctioning.

A patient has been discharged home on parenteral nutrition (PN). Much of the nurse's discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply. A) Changes in lifestyle B) Loss of eating as a social behavior C) Chronic bowel incontinence from GI changes D) Sleep disturbances related to frequent urination during nighttime infusions E) Stress of choosing the correct PN formulation

Ans: A) Changes in lifestyle B) Loss of eating as a social behavior D) Sleep disturbances related to frequent urination during nighttime infusions Feedback: Patients must cope with the loss of eating as a social behavior and with changes in lifestyle brought on by sleep disturbances related to frequent urination during night time infusions. PN is not associated with bowel incontinence and the patient does not select or adjust the formulation of PN.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A) Checking the patient's capillary blood glucose levels regularly B) Having the patient frequently rate his or her hunger on a 10-point scale C) Measuring the patient's heart rhythm at least every 6 hours D) Monitoring the patient's level of consciousness each shift

Ans: A) Checking the patient's capillary blood glucose levels regularly Feedback: The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. This is a more salient threat than hunger, though this should be addressed. Dysrhythmias and decreased LOC are not among the most common complications.

A patient's health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication? A) Chemical phlebitis B) Hyperglycemia C) Dumping syndrome D) Line sepsis

Ans: A) Chemical phlebitis Feedback: Formulations with dextrose concentrations of more than 10% should not be administered through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Hyperglycemia and line sepsis are risks with both peripheral and central administration of PN. PN is not associated with dumping syndrome.

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps? A) Colonoscopy B) Barium enema C) ERCP D) Upper gastrointestinal fibroscopy

Ans: A) Colonoscopy Feedback: During colonoscopy, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy.

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care? A) Confirm placement of the tube prior to each medication administration. B) Have the patient sip cool water to stimulate saliva production. C) Keep the patient in a low Fowler's position when at rest. D) Connect the tube to continuous wall suction when not in use.

Ans: A) Confirm placement of the tube prior to each medication administration Feedback: Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a nasogastric tube the patient should be positioned in a Fowler's position. Oral fluid administration is contraindicated by the patient's dysphagia.

A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the patient's gastrointestinal function? Select all that apply. A) Decreased motility B) Increased sphincter tone C) Increased enzyme release D) Inhibition of secretions E) Increased peristalsis

Ans: A) Decreased motility Feedback: Norepinephrine generally decreases GI motility and secretions, but increases muscle tone of sphincters. Norepinephrine does not increase the release of enzymes.

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection? A) Indicates acceptance of altered appearance and demonstrates positive self-image B) Freely expresses needs and concerns related to postoperative pain management C) Compensates effectively for alteration in ability to communicate related to dysarthria D) Demonstrates effective stress management techniques to promote muscle relaxation

Ans: A) Indicates acceptance of altered appearance and demonstrates positive self-image Feedback: Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patients appearance is visibly altered. The face generally appears asymmetric, with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patients level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation.

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A) Inflammatory bowel disease B) Intestinal polyps C) Diverticulitis D) Colon cancer

Ans: A) Inflammatory bowel disease Feedback: The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis.

The nurse is preparing to perform a patient's abdominal assessment. What examination sequence should the nurse follow? A) Inspection, auscultation, percussion, and palpation B) Inspection, palpation, auscultation, and percussion C) Inspection, percussion, palpation, and auscultation D) Inspection, palpation, percussion, and auscultation

Ans: A) Inspection, auscultation, percussion, and palpation Feedback: When performing a focused assessment of the patient's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation.

A nurse is preparing to administer a patient's intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurse's action? A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B) The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D) The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

Ans: A) Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered Feedback: Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. The patient does not need another intravenous line for the fat emulsion. The IVFE cannot be piggy-backed into any existing IV solution that is infusing.

A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the patient's care? A) Measure and record drainage. B) Monitor drainage for change in color. C) Titrate the suction every hour. D) Feed the patient via the G tube as ordered.

Ans: A) Measure and record drainage Feedback: This drainage should be measured and recorded because it is a significant indicator of GI function. The nurse should indeed monitor the color of the output, but fluid balance is normally the priority. Frequent titration of the suction should not be necessary and feeding is contraindicated if the G tube is in place for drainage.

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample? A) NSAIDs B) Acetaminophen C) OTC vitamin D supplements D) Fiber supplements

Ans: A) NSAIDs Feedback: NSAIDs can cause a false-positive fecal occult blood test. Acetaminophen, vitamin D supplements, and fiber supplements do not have this effect.

An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? A) Palpate the patients parotid glands to detect swelling and tenderness. B) Assess the temporomandibular joint for evidence of a malocclusion. C) Test the integrity of cranial nerve XII by asking the patient to protrude the tongue. D) Inspect the patients gums for bleeding and hyperpigmentation.

Ans: A) Palpate the patients parotid glands to detect swelling and tenderness Feedback: Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.

A nurse is promoting increased protein intake to enhance a patient's wound healing. The nurse knows that enzymes are essential in the digestion of nutrients such as protein. What is the enzyme that initiates the digestion of protein? A) Pepsin B) Intrinsic factor C) Lipase D) Amylase

Ans: A) Pepsin Feedback: The enzyme that initiates the digestion of protein is pepsin. Intrinsic factor combines with vitamin B12 for absorption by the ileum. Lipase aids in the digestion of fats and amylase aids in the digestion of starch.

An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? A) Percussion B) Auscultation C) Inspection D) Rectal examination

Ans: A) Percussion Feedback: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.

A nurse is preparing to place a patient's ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube? A) Place distal tip to nose, then ear tip and end of xiphoid process. B) Instruct the patient to lie prone and measure tip of nose to umbilical area. C) Insert the tube into the patient's nose until secretions can be aspirated. D) Obtain an order from the physician for the length of tube to insert.

Ans: A) Place distal top to nose, then ear tip and end of xiphoid process Feedback: Tube length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 6 inches for NG placement or at least 8 to 10 inches or more for intestinal placement, although studies do not necessarily confirm that this is a reliable technique. The physician would not prescribe a specific length and the umbilicus is not a landmark for this process. Length is not determined by aspirating from the tube.

A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? A) Premature removal of the G tube B) Bowel perforation C) Constipation D) Development of peptic ulcer disease (PUD)

Ans: A) Premature removal of the G tube Feedback: A significant postoperative complication of a gastrostomy is premature removal of the G tube. Constipation is a less immediate threat and bowel perforation and PUD are not noted to be likely complications.

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion D) Teaching the patient to flush the line with sterile water E) Teaching the patient when it is safe to leave the access site open to air

Ans: A) Preparing the patient to troubleshoot for problems B) Teaching the patient and family strict aseptic technique C) Teaching the patient and family how to set up the infusion Feedback: An effective home care teaching program prepares the patient to store solutions, set up the infusion, flush the line with heparin, change the dressings, and troubleshoot for problems. The most common complication is sepsis. Strict aseptic technique is taught for hand hygiene, handling equipment, changing the dressing, and preparing the solution. Sterile water is never used for flushes and the access site must never be left open to air.

A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care? A) Risk for Aspiration Related to Inhalation of Gastric Contents B) Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption C) Risk for Decreased Cardiac Output Related to Vasovagal Response D) Risk for Impaired Verbal Communication Related to Oral Trauma

Ans: A) Risk for Aspiration Related to Inhalation of Gastric Contents Feedback: Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the patients nutritional status and does not affect cardiac output or communication.

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. A) Splenic vein B) Inferior mesenteric vein C) Gastric vein D) Inferior vena cava E) Saphenous vein

Ans: A) Splenic vein B) Inferior mesenteric vein C) Gastric vein Feedback: This portal venous system is composed of five large veins: the superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins, which eventually form the vena portae that enters the liver. The inferior vena cava is not part of the portal system. The saphenous vein is located in the leg.

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patient's health complaint? A) Stomach emptying takes place more slowly. B) The villi and epithelium of the small intestine become thinner. C) The esophageal sphincter becomes incompetent. D) Saliva production decreases.

Ans: A) Stomach emptying takes place more slowly Feedback: Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change.

A medical patient's CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding? A) The patient may have cancer, but other GI disease must be ruled out. B) The patient most likely has early-stage colorectal cancer. C) The patient has a genetic predisposition to gastric cancer. D) The patient has cancer, but the site is unknown.

Ans: A) The patient may have cancer, but other GI disease must be ruled out Feedback: CA 19-9 levels are elevated in most patients with advanced pancreatic cancer, but they may also be elevated in other conditions such as colorectal, lung, and gallbladder cancers; gallstones; pancreatitis; cystic fibrosis; and liver disease. A cancer diagnosis cannot be made solely on CA 19-9 results.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The patient will require an upper endoscopy every 6 months to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside.

Ans: A) The patient will require an upper endoscopy every 6 months to detect malignant changes Feedback: In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect? A) The patient's BUN and creatinine levels are within reference range following the CT. B) The CT yields high-quality images. C) The patient's electrolytes are stable in the 48 hours following the CT. D) The patient's intake and output are in balance on the day after the CT.

Ans: A) The patient's BUN and creatinine levels are within reference range following the CT Feedback: Both sodium bicarbonate and Mucomyst are free radical scavengers that sequester the contrast byproducts that are destructive to renal cells. Kidney damage would be evident by increased BUN and creatinine levels. These medications are unrelated to electrolyte or fluid balance and they play no role in the results of the CT.

A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A) The patients swallowing ability B) The patients ability to speak C) The patients management of secretions D) The patients airway patency

Ans: A) The patients swallowing ability Feedback: If the superior laryngeal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only affects management of secretions and airway patency indirectly.

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply. A) To remove gas from the stomach B) To administer clotting factors to treat a GI bleed C) To remove toxins from the stomach D) To open sphincters that are closed E) To diagnose GI motility disorders

Ans: A) To remove gas from the stomach C) To remove toxins from the stomach E) To diagnose GI motility disorders Feedback: GI intubation may be performed to decompress the stomach and remove gas and fluid, lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials, diagnose disorders of GI motility and other disorders, administer medications and feedings, compress a bleeding site, and aspirate gastric contents for analysis. GI intubation is not used for opening sphincters that are not functional or for administering clotting factors.

A female patient has presented to the emergency department with right upper quadrant pain; the physician has ordered abdominal ultrasound to rule out cholecystitis (gallbladder infection). The patient expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A) "Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B) "Abdominal ultrasound poses no known safety risks of any kind." C) "Current guidelines state that a person can have up to 3 ultrasounds per year." D) "Current guidelines state that a person can have up to 6 ultrasounds per year."

Ans: B) "Abdominal ultrasound poses no known safety risks of any kind" Feedback: An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy.

A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patient's history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool? A) A laparoscopic intestinal mucosa biopsy B) A quantitative fecal immunochemical test C) Computed tomography (CT) D) Magnetic resonance imagery (MRI)

Ans: B) A quantitative fecal immunochemical test Feedback: Quantitative fecal immunochemical tests may be more accurate than guaiac testing and useful for patients who refuse invasive testing. CT or MRI cannot detect blood in stool. Laparoscopic intestinal mucosa biopsy is not performed.

A patient's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A) Withdraw the NG tube 3 to 5 cm and reattempt aspiration. B) Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C) Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D) Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

Ans: B) Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating Feedback: When a tube is first noted to be clogged, a 30- to 60-mL syringe should be attached to the end of the tube and any contents aspirated and discarded. Then the syringe should be filled with warm water, attached to the tube again, and a back-and-forth motion initiated to help loosen the clog. Removal is not warranted at this early stage and a flicking motion is not recommended. The tube should not be withdrawn, even a few centimeters.

A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include? A) Increasing calcium intake to promote bone healing B) Avoiding chewing food for the specified number of weeks after surgery C) Techniques for managing parenteral nutrition in the home setting D) Techniques for managing a gastrostomy

Ans: B) Avoiding chewing food for the specified number of weeks after surgery Feedback: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary.

A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain? A) Midline near the umbilicus B) Below the right nipple C) Left groin area D) Right lower abdominal quadrant

Ans: B) Below the right nipple Feedback: Patients with referred abdominal pain associated with biliary colic complain of pain below the right nipple. Referred pain above the left nipple may be associated with the heart. Groin pain may be referred pain from ureteral colic.

A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A) Use clean technique and wear a mask during dressing changes. B) Change the dressing no more than weekly. C) Apply antibiotic ointment around the site with each dressing change. D) Irrigate the insertion site with sterile water during each dressing change.

Ans: B) Change the dressing no more than weekly Feedback: The CDC (2011) recommends changing CVAD dressings not more than every 7 days unless the dressing is damp, bloody, loose, or soiled. Sterile technique (not clean technique) is used. Irrigation and antibiotic ointments are not used.

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patient's care plan should include nursing actions relevant to what potential complications? Select all that apply. A) Dumping syndrome B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis

Ans: B) Clotted or displaced catheter C) Pneumothorax D) Hyperglycemia E) Line sepsis Feedback: Common complications of PN include a clotted or displaced catheter, pneumothorax, hyperglycemia, and infection from the venous access device (line sepsis). Dumping syndrome applies to enteral nutrition, not PN.

A patient's enteral feedings have been determined to be too concentrated based on the patient's development of dumping syndrome. What physiologic phenomenon caused this patient's complication of enteral feeding? A) Increased gastric secretion of HCl and gastrin because of high osmolality of feeds B) Entry of large amounts of water into the small intestine because of osmotic pressure C) Mucosal irritation of the stomach and small intestine by the high concentration of the feed D) Acid-base imbalance resulting from the high volume of solutes in the feed

Ans: B) Entry of large amounts of water into the small intestine because of osmotic pressure Feedback: When a concentrated solution of high osmolality entering the intestines is taken in quickly or in large amounts, water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. This results in dumping syndrome. Dumping syndrome is not the result of changes in HCl or gastrin levels. It is not caused by an acid-base imbalance or direct irritation of the GI mucosa.

A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds? A) Normal B) Hypoactive C) Hyperactive D) Paralytic ileus

Ans: B) Hypoactive Feedback: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.

A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patient's plan of care, which of the following nursing diagnoses should be included? A) Risk for Peripheral Neurovascular Dysfunction Related to Catheter Placement B) Ineffective Role Performance Related to Parenteral Nutrition C) Bowel Incontinence Related to Parenteral Nutrition D) Chronic Pain Related to Catheter Placement

Ans: B) Ineffective Role Performance Related to Parenteral Nutrition Feedback: The limitations associated with PN can make it difficult for patients to maintain their usual roles. PN does not normally cause bowel incontinence and catheters are not associated with chronic pain or neurovascular dysfunction.

A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions? A) Starting with a rapid infusion rate to meet the patient's nutritional needs as quickly as possible B) Initiating the infusion slowly and monitoring the patient's fluid and glucose tolerance C) Changing the rate of administration every 2 hours based on serum electrolyte values D) Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

Ans: B) Initiating the infusion slowly and monitoring the patient's fluid and glucose tolerance Feedback: PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patient's fluid and glucose tolerance permits. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient based on clinical findings and laboratory data. It is not infused more quickly at mealtimes.

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? A) Prime the tubing with 20 mL of normal saline. B) Keep the vent lumen above the patient's waist. C) Maintain the patient in a high Fowler's position. D) Have the patient pin the tube to the thigh.

Ans: B) Keep the vent lumen above the patient's waist Feedback: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way anti-reflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, the nurse does not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

A nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. A) Pepsin B) Lipase C) Amylase D) Trypsin E) Ptyalin

Ans: B) Lipase C) Amylase D) Trypsin Feedback: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Pepsin is secreted by the stomach and ptyalin is secreted in the saliva.

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A) Pyloric sphincter B) Lower esophageal sphincter C) Hypopharyngeal sphincter D) Upper esophageal sphincter

Ans: B) Lower esophageal sphincter Feedback: The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.

A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patient's ability to swallow? A) Temporal lobe B) Medulla oblongata C) Cerebellum D) Pons

Ans: B) Medulla oblongata Feedback: Swallowing is a voluntary act that is regulated by a swallowing center in the medulla oblongata of the central nervous system. Swallowing is not regulated by the temporal lobe, cerebellum, or pons.

A patient's physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device? A) Peripheral catheter B) Nontunneled central catheter C) Implantable port D) Tunneled central catheter

Ans: B) Nontunneled central catheter Feedback: Nontunneled central catheters are used for short-term (less than 6 weeks) IV therapy. A peripheral catheter can be used for the administration of peripheral parenteral nutrition for 5 to 7 days. Implantable ports and tunneled central catheters are for long-term use and may remain in place for many years. Peripherally inserted central catheters (PICCs) are another potential option.

Results of a patient's preliminary assessment prompted an examination of the patient's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding? A) Perform a focused abdominal assessment. B) Prepare to meet the patient's psychosocial needs. C) Liaise with the nurse practitioner to perform an anorectal examination. D) Encourage the patient to adhere to recommended screening protocols.

Ans: B) Prepare to meet the patient;s psychosocial needs Feedback: CEA is a protein that is normally not detected in the blood of a healthy person; therefore, when detected it indicates that cancer is present, but not what type of cancer is present. The patient would likely be learning that he or she has cancer, so the nurse must prioritize the patient's immediate psychosocial needs, not abdominal assessment. Future screening is not a high priority in the short term.

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action? A) Prevent gastric ulcers B) Prevent aspiration C) Prevent abdominal distention D) Prevent diarrhea

Ans: B) Prevent aspiration Feedback: Protecting the client from aspirating is essential because aspiration can cause pneumonia, a potentially life-threatening disorder. Gastric ulcers are not a common complication of tube feeding in clients with ET tubes. Abdominal distention and diarrhea can both be associated with tube feeding, but prevention of these problems is not the primary rationale for confirming placement.

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action? A) Document the findings as being consistent with a viable graft. B) Promptly report these indications of venous congestion. C) Closely monitor the patient and reassess in 30 minutes. D) Reposition the patient to promote peripheral circulation.

Ans: B) Promptly report these indications of venous congestion Feedback: A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom? A) Burning pain on swallowing B) Regurgitation of undigested food C) Symptoms mimicking a heart attack D) Chronic parotid abscesses

Ans: B) Regurgitation of undigested food Feedback: An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the patient assumes a recumbent position. The patient may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum.

A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan? A) Risk for Excess Fluid Volume Related to Enteral Feedings B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube C) Risk for Unstable Blood Glucose Related to Enteral Feedings D) Risk for Impaired Verbal Communication Related to Presence of NG Tube

Ans: B) Risk for Impaired Skin Integrity Related to the Presence of NG Tube Feedback: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This patient's NG tube is in place for decompression, so complications of enteral feeding do not apply.

A patient has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test? A) Impaired Dentition Related to Gingivitis B) Risk For Impaired Skin Integrity Related to Peptic Ulcers C) Imbalanced Nutrition: Less Than Body Requirements Related to Enzyme Deficiency D) Diarrhea Related to Clostridium Difficile Infection

Ans: B) Risk for impaired skin integrity related to peptic ulcers Feedback: Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. This test does not address fluid volume, nutritional status, or dentition.

A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize? A) Risk for Activity Intolerance Related to the Presence of a Subclavian Catheter B) Risk for Infection Related to the Presence of a Subclavian Catheter C) Risk for Functional Urinary Incontinence Related to the Presence of a Subclavian Catheter D) Risk for Sleep Deprivation Related to the presence of a Subclavian Catheter

Ans: B) Risk for infection related to the presence of a subclavian catheter Feedback: The high glucose content of PN solutions makes the solutions an idea culture media for bacterial and fungal growth, and the central venous access devices provide a port of entry. Prevention of infection is consequently a high priority. The patient will experience some inconveniences with regard to toileting, activity, and sleep, but the infection risk is a priority over each of these.

A patient's sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patient's discharge education? A) The patient should drink at least 2 liters of fluid in the next 12 hours. B) The patient can resume a normal routine immediately. C) The patient should expect fecal urgency for several hours. D) The patient can expect some scant rectal bleeding.

Ans: B) The patient can resume a normal routine immediately Feedback: Following sigmoidoscopy, patients can resume their regular activities and diet. There is no need to push fluids and neither fecal urgency nor rectal bleeding is expected.

The nurse is preparing to insert a patient's ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement? A) The patient is obese and has a "short neck." B) The patient is agitated. C) The patient has a history of gastroesophageal reflux disease (GERD). D) The patient is being treated for pneumonia.

Ans: B) The patient is agitated Feedback: Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion. A "short neck," GERD, and pneumonia are not linked to incorrect placement.

A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A) Sigmoid colon B) Upper GI tract C) Large intestine D) Anus or rectum

Ans: B) Upper GI tract Feedback: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? A) Administer antibiotics via the tube as ordered. B) Wash the area around the tube with soap and water daily. C) Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. D) Irrigate the skin surrounding the insertion site with normal saline before each use.

Ans: B) Wash the area around the tube with soap and water daily Feedback: Infection can be prevented by keeping the skin near the insertion site clean using soap and water. Hydrogen peroxide is not used, due to associated skin irritation. The skin around the site is not irrigated with normal saline and antibiotics are not administered to prevent site infection.

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly? A) "I clean my stoma twice a day with alcohol." B) "The only time I flush my tube is when I'm putting in medications." C) "I flush my tube with water before and after each of my medications." D) "I try to stay still most of the time to avoid dislodging my tube."

Ans: C) " I flush my tube with water before and after each of my medications" Feedback: Frequent flushing is needed to prevent occlusion, and should not just be limited to times of medication administration. Alcohol will irritate skin surrounding the insertion site and activity should be maintained as much as possible.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation? A) "You'll need to fast for at least 18 hours prior to your test." B) "Starting today, take over-the-counter stool softeners twice daily." C) "You'll need to have enemas the day before the test." D) "For 24 hours before the test, insert a glycerin suppository every 4 hours."

Ans: C) "You'll need to have enemas the day before the test" Feedback: Preparation of the patient includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed? A) 2 weeks B) 4 to 6 weeks C) 2 to 3 months D) 4 to 6 months

Ans: C) 2 to 3 months Feedback: An alternative to the PEG device is a low-profile gastrostomy device (LPGD). LPGDs may be inserted 2 to 3 months after initial gastrostomy tube placement.

A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis? A) A patient who is receiving intravenous antibiotic therapy in the home setting B) A patient who has a chronic venous ulcer C) An older adult whose medication regimen includes an anticholinergic D) A patient with poorly controlled diabetes who receives weekly wound care

Ans: C) An older adult whose medication regimen includes an anticholinergic Feedback: Elderly, acutely ill, or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis. Anticholinergic medications inhibit saliva production. Antibiotics, diabetes, and wounds are not risk factors for parotitis.

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A) Assess ability to clear oral secretions. B) Assess for signs of infection. C) Assess for a patent airway. D) Assess for ability to communicate.

Ans: C) Assess for a patent airway Feedback: Postoperatively, the nurse assesses for a patent airway. The patients ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A) Keep the head of the bed lowered. B) Drink a cup of hot tea before bedtime. C) Avoid carbonated drinks. D) Eat a low-protein diet.

Ans: C) Avoid carbonated drinks Feedback: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.

Prior to a patient's scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? A) Determining the patient's nutritional needs B) Determining that the patient fully understands the postoperative care required C) Determining the patient's ability to understand and cooperate with the procedure D) Determining the patient's ability to cope with an altered body image

Ans: C) Determining the patient's ability to understand and cooperate with the procedure Feedback: The major focus of the preoperative assessment is to determine the patient's ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate? A) Stop the tube feed and aspirate stomach contents. B) Increase the hourly feed rate so it finishes earlier. C) Dilute the concentration of the feeding solution. D) Administer fluid replacement by IV.

Ans: C) Dilute the concentration of the feeding solution Feedback: Dumping syndrome can generally be alleviated by starting with a dilute solution and then increasing the concentration of the solution over several days. Fluid replacement may be necessary but does not prevent or treat dumping syndrome. There is no need to aspirate stomach contents. Increasing the rate will exacerbate the problem.

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? A) Promotion of a nutrient-dense, low-fat diet B) Annual screening endoscopy for patients over 50 with a family history of esophageal cancer C) Early diagnosis and treatment of gastroesophageal reflux disease D) Adequate fluid intake and avoidance of spicy foods

Ans: C) Early diagnosis and treatment of gastroesophageal reflux disease Feedback: There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? A) Stool will be yellow for the first 24 hours postprocedure. B) The barium may cause diarrhea for the next 24 hours. C) Fluids must be increased to facilitate the evacuation of the stool. D) Slight anal bleeding may be noted as the barium is passed.

Ans: C) Fluids must be increased to facilitate the evacuation of the stool Feedback: Postprocedural patient education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements, because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimer's disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurse's assessments addresses this patient's most significant potential complication of feeding? A) Frequent assessment of the patient's abdominal girth B) Assessment for hemorrhage from the nasal insertion site C) Frequent lung auscultation D) Vigilant monitoring of the frequency and character of bowel movements

Ans: C) Frequent lung auscultation Feedback: Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the patient's cognitive deficits. Consequently, the nurse should auscultate the patient's lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the patient's abdominal girth is not a main focus of assessment.

A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patient's abdomen. How should the nurse best interpret this assessment finding? A) Abdominal lesions are usually due to age-related skin changes. B) Integumentary diseases often cause GI disorders. C) GI diseases often produce skin changes. D) The patient needs to be assessed for self-harm.

Ans: C) GI diseases often produce skin changes Feedback: Abdominal lesions are of particular importance, because GI diseases often produce skin changes. Skin problems do not normally cause GI disorders. Age-related skin changes do not have a pronounced effect on the skin of the abdomen when compared to other skin surfaces. Self-harm is a less likely explanation for skin lesions on the abdomen.

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown? A) Verify tube placement. B) Loop adhesive tape around the tube and connect it securely to the abdomen. C) Gently rotate the tube. D) Change the wet-to-dry dressing.

Ans: C) Gently rotate the tube Feedback: The nurse verifies the tube's placement and gently rotates the tube once daily to prevent skin breakdown. Verifying tube placement and taping the tube to the abdomen do not prevent skin breakdown. A gastrostomy wound does not have a wet-to-dry dressing.

A clinic patient has described recent dark-colored stools;the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patient's current health status would contraindicate FOBT? A) Gastroesophageal reflux disease (GERD) B) Peptic ulcers C) Hemorrhoids D) Recurrent nausea and vomiting

Ans: C) Hemorrhoids Feedback: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.

A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of? A) Diet high in red meat B) Upper GI bleed C) Hemorrhoids D) Use of iron supplements

Ans: C) Hemorrhoids Feedback: Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool. Hemorrhoids are often a cause of anal bleeding since they occur in the rectum. Blood from an upper GI bleed would be dark rather than frank. Iron supplements make the stool dark, but not bloody and red meat consumption would not cause frank blood.

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what? A) 5% deficit in body weight compared to preillness weight and increased caloric need B) Calorie deficit and muscle wasting combined with low electrolyte levels C) Inability to take in adequate oral food or fluids within 7 days D) Significant risk of aspiration coupled with decreased level of consciousness

Ans: C) Inability to take in adequate oral food or fluids within 7 days Feedback: The indications for PN include an inability to ingest adequate oral food or fluids within 7 days. Weight loss, muscle wasting combined with electrolyte imbalances, and aspiration indicate a need for nutritional support, but this does not necessary have to be parenteral.

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A)Remain NPO for 6 hours postprocedure. B) Administer a Fleet enema to cleanse the bowel of the barium. C) Increase fluid intake to evacuate the barium. D) Avoid dairy products for 24 hours postprocedure.

Ans: C) Increase fluid intake to evacuate the barium Feedback: Adequate fluid intake is necessary to rid the GI tract of barium. The patient must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurse's most appropriate action? A) Inform the physician that the tube may be in the patient's pleural space. B) Withdraw the tube 2 to 4 cm. C) Leave the tube in its present position. D) Advance the tube up to 8 cm.

Ans: C) Leave the tube in its present position Feedback: The patient's aspirate is from the gastric area when the nurse observes that the color of the aspirate is green. Further confirmation of placement is necessary, but there is likely no need for repositioning. Pleural secretions are pale yellow.

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test? A) In a knee-chest position (lithotomy position) B) Lying prone with legs drawn toward the chest C) Lying on the left side with legs drawn toward the chest D) In a prone position with two pillows elevating the buttocks

Ans: C) Lying on the left side with legs drawn toward the chest Feedback: For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A kneechest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include? A) Muscle training to relieve dysphagia B) Relieving nerve paralysis in the cervical plexus C) Promoting maximum shoulder function D) Alleviating achalasia by decreasing esophageal peristalsis

Ans: C) Promoting maximum shoulder function Feedback: Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the patients neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist.

A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education? A) Resumption of activities of daily living B) Pain control C) Promotion of adequate nutrition D) Strategies for promoting communication

Ans: C) Promotion of adequate nutrition Feedback: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the patients nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery.

A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patient's family asks the nurse why the physician is recommending the removal of the patient's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A) It eliminates the risk for infection. B) Feeds can be infused at a faster rate. C) Regurgitation and aspiration are less likely. D) It allows caregivers to provide personal hygiene more easily.

Ans: C) Regurgitation and aspiration are less likely Feedback: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG feedings. Both tubes carry a risk for infection; this change in care is not motivated by the possibility of faster infusion or easier personal care.

The nurse is caring for a patient with a duodenal ulcer and is relating the patient's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A) Secretion of hydrochloric acid (HCl) B) Reabsorption of water C) Secretion of mucus D) Absorption of nutrients E) Movement of nutrients into the bloodstream

Ans: C) Secretion of mucus D) Absorption of nutrients E) Movement of nutrients into the bloodstream Feedback: The small intestine folds back and forth on itself, providing approximately 7000 cm2 (70 m2) of surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. Water reabsorption primarily takes place in the large bowel. HCl is secreted by the stomach.

A nurse is participating in a patient's care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN? A) TNA can be mixed by a certified registered nurse. B) TNA can be administered over 8 hours, while PN requires 24-hour administration. C) TNA is less costly than PN. D) TNA does not require the use of a micron filter.

Ans: C) TNA is less costly than PN Feedback: TNA is mixed in one container and administered to the patient over a 24-hour period. A 1.5-micron filter is used with the TNA solution. Advantages of the TNA over PN include cost savings. Pharmacy staff must prepare both solutions.

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract? A) The breakdown of food particles into cell form for digestion B) The maintenance of fluid and acid-base balance C) The absorption into the bloodstream of nutrient molecules produced by digestion D) The control of absorption and elimination of electrolytes

Ans: C) The absorption into the bloodstream of nutrient molecules produced by digestion Feedback: Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient? A) "Take all your medications as usual." B) "Take all your medications except the antihypertensive medications." C) "Don't eat highly acidic foods 72 hours before you start the test." D) "Avoid vitamin C for 72 hours before you start the test."

Ans: D) "Avoid vitamin C for 72 hours before you start the test" Feedback: Red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study, because they may cause a false-positive result. Also, ingestion of vitamin C from supplements or foods can cause a false-negative result. Acidic foods do not need to be avoided.

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurse's best response? A) Adhesive holds a flange in place against the abdominal skin. B) A stitch holds the tube in place externally. C) The tube is stitched to the abdominal skin externally and the stomach wall internally. D) An internal retention disc secures the tube against the stomach wall.

Ans: D) An internal retention disc secures the tube against the stomach wall Feedback: A PEG tube is held in place by an internal retention disc (flange) that holds it against the stomach wall. It is not held in place by stitches or adhesives.

A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient? A) Insert a nasogastric tube. B) Administer a micro Fleet enema at least 3 hours before the procedure. C) Have the patient lie in a supine position for the procedure. D) Apply local anesthetic to the back of the patient's throat.

Ans: D) Apple local anesthetic to the back of the patient's throat Feedback: Preparation for UGF includes spraying or gargling with a local anesthetic. A nasogastric tube or a micro Fleet enema is not required for this procedure. The patient should be positioned in a side-lying position in case of emesis.

A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery? A) Assessing function of cranial nerves V, VI, and IX B) Assessing for a history of GERD C) Assessing for signs or symptoms of atherosclerosis D) Assessing the patency of the ulnar artery

Ans: D) Assessing the patency of the ulnar artery Feedback: If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The success of this surgery is not primarily dependent on CN function or the absence of GERD and atherosclerosis.

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation? A) Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash B) Applying a water-soluble gel to the teeth and gums C) Wiping the teeth and gums clean with a gauze pad D) Brushing the patients teeth with a toothbrush and small amount of toothpaste

Ans: D) Brushing the patients teeth with a toothbrush and a small amount of toothpaste Feedback: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.

A nurse is preparing to administer a patient's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurse's best action? A) Recognize this as an expected finding. B) Place the bag in a warm environment for 30 minutes. C) Shake the bag vigorously for 10 to 20 seconds. D) Contact the pharmacy to obtain a new bag of PN.

Ans: D) Contact the pharmacy to obtain a new bag of PN Feedback: Before PN infusion is administered, the solution must be inspected for separation, oily appearance (also known as a "cracked solution"), or any precipitate (which appears as white crystals). If any of these are present, it is not used. Warming or shaking the bag is inappropriate and unsafe.

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A) Increased gastric motility B) Decreased gastric pH C) Increased gag reflex D) Decreased mucus secretion

Ans: D) Decreased mucus secretion Feedback: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.

A patient with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The patient's intake of trypsin facilitates what aspect of GI function? A) Vitamin D synthesis B) Digestion of fats C) Maintenance of peristalsis D) Digestion of proteins

Ans: D) Digestion of proteins Feedback: Trypsin facilitates the digestion of proteins. It does not influence vitamin D synthesis, the digestion of fats, or peristalsis.

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A) Haloperidol B) Prostigmine C) Epinephrine D) Glucagon

Ans: D) Glucagon Feedback: Glucagon is administered prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for patients with myastheniagravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm.

A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A) Risk for Disuse Syndrome B) Unilateral Neglect C) Risk for Trauma D) Ineffective Tissue Perfusion

Ans: D) Ineffective Tissue Perfusion Feedback: Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.

A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube? A) Nasogastric tube B) Levin tube C) Gastric sump D) Orogastric tube

Ans: D) Orogastric tube Feedback: An orogastric tube is a large-bore tube inserted through the mouth with a wide outlet for removal of gastric contents; it is used primarily in the emergency department or an intensive care setting. Nasogastric, Levin, and gastric sump tubes are not used for this specific purpose.

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A) Muscle wasting B) Chronic jaundice in the absence of liver disease C) The presence of fat in the patient's stool D) Persistently low hemoglobin and hematocrit

Ans: D) Persistently low hemoglobin and hematocrit Feedback: In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results. This would result in a marked reduction in hemoglobin and hematocrit.

A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patient's oxygen saturation is 89% by pulse oximetry. After ensuring the patient's immediate safety, what is the nurse's most appropriate action? A) Perform chest physiotherapy. B) Reduce the height of the patient's bed and remove the NG tube. C) Liaise with the dietitian to obtain a feeding solution with lower osmolarity. D) Report possible signs of aspiration pneumonia to the primary care provider.

Ans: D) Report possible signs of aspiration pneumonia to the primary care provider Feedback: The patient should be assessed for further signs of aspiration pneumonia. It is unnecessary to remove the NG tube and chest physiotherapy is not indicated. A different feeding solution will not resolve this complication.

A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action? A) Encourage the patient to perform deep breathing and coughing exercises hourly. B) Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula. C) Activate the emergency response system. D) Report this finding promptly to the physician and remain with the patient.

Ans: D) Report this finding promptly to the physician and remain with the patient Feedback: In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.

A nurse has obtained an order to remove a patient's NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action? A) Gently twist the tube before pulling. B) Instill a digestive enzyme solution and reattempt removal in 10 to 15 minutes. C) Flush the tube with hot tap water and reattempt removal. D) Report this finding to the patient's primary care provider.

Ans: D) Report this finding to the patient's primary care provider Feedback: If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. Enzymes are used to resolve obstructions, not to aid removal. For safety reasons, hot water is never instilled into a tube. Twisting could cause damage to the mucosa.

An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician? A) Large, wide stools B) Milky white stools C) Three stools during an 8-hour period of time D) Streaks of blood present in the stool

Ans: D) Streaks of blood present in the stool Feedback: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.

A patient with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the patient, what advantage should the nurse describe? A) The test allows visualization of the entire peritoneal cavity. B) The test allows for painless biopsy collection. C) The test does not require fasting. D) The test is noninvasive.

Ans: D) The test is noninvasive Feedback: Capsule endoscopy allows the noninvasive visualization of the mucosa throughout the entire small intestine. Bowel preparation is necessary and biopsies cannot be collected. This procedure allows visualization of the entire GI tract, but not the peritoneal cavity.

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? A) Auscultate the patient's abdomen after injecting air through the tube. B) Assess the color and pH of aspirate. C) Locate the marking made after the initial x-ray confirming placement. D) Use a combination of at least two accepted methods for confirming placement.

Ans: D) Use a combination of at least two accepted methods for confirming placement Feedback: There are a variety of methods to check tube placement. The safest way to confirm placement is to utilize a combination of assessment methods.