A&C I Gastrointestinal #4

A nurse is caring for a client who has an active upper GI bleed. After inserting a NG tube into the client, which of the collowing findings should the nurse anticipate?

Coffee-ground drainage "Coffee-ground" drainage or emesis indicates the presence of blood. The coffee ground appearance is the result of the effects of methemoglobin on the hemoglobin.

A nurse is teaching a client who has a prescription of a NG tube to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

Decompress the stomach. A pyloric obstruction, also called gastric outlet obstruction, is caused by edema, scarring, or spasm, often the result of gastritis or peptic ulcer disease. The nurse should inform the client that because the stomach is dilated and may contain undigested food, it must be decompressed, necessitating the placement of an NG tube.

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of GI perforation?

Sudden abdominal pain Classic indications of gastrointestinal perforation include sudden sharp abdominal pain with a rigid abdomen, declining peristalsis, and progression to septicemia and hypovolemic shock.

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?

Sudden decrease in abdominal pain A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

-Broth -Grape juice - Lemon gelatin Fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable. Lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops. Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice.

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?

Intussusception These findings are associated with a diagnosis of intussusception. Other associated findings include vomiting, lethargy, periods of screaming and drawing the knees to the chest followed by periods of normal behavior, and eventual fever and signs of peritonitis.

A parent calls a clinic and reports to a nurse that his 2 month old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make?

"Bring your baby in to the clinic today." Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible.

A nurse is providing teaching to a client with gastroesophageal reflux. Which of the following statements by the client indicates a need for further teaching?

"I drink no more than 4 cups of coffee a day." The client should not consume regular or decaffeinated beverages; therefore, this statement by the client indicates a need for further teaching.

A nurse is caring for a client who is post-op following an appendectomy and is prescribed D lactated Ringer's at mL/hr by continuous IV infusion for hr. The drop factor of the manual IV tubing is 20 gtt/ mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

50 MY ANSWER STEP 1: What is the unit of measurement the nurse should calculate? gtt/min STEP 2: What is the volume the nurse should infuse? 150 mL/hr STEP 3: What is the total infusion time? 1 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 1 hr/60 min STEP 5: Set up an equation and solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL) = X 150 mL/60 min x 20 gtt/mL = X gtt/min X = 50 STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads D5 lactated Ringer's 150 mL continuous IV infusion for 12 hr, it makes sense to administer 50 gtt/min. The nurse should set the manual IV infusion to deliver D5 lactated Ringer's IV at 50 gtt/min.

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

Administer sodium biphosphate/sodium phosphate. Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis.

A nurse is caring for a client who has GI bleeding. Which of the following actions should the nurse take first?

Assess orthostatic blood pressure. Using the nursing process, the first action the nurse should take is to assess the client by measuring the client's orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements.

A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?

Avoid eating within 3 hr of bedtime. The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime.

A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet

Dried apricots A nurse should instruct a client who has ulcerative colitis to consume a diet low in fiber and should eliminate dried apricots from his diet. Dried apricots are high in fiber and may cause an exacerbation of the client's disease process.

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nruse identify as the priority?

Hematemesis When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in mechanical obstruction. The nurse should identify this finding as a manifestation of which of the followign disorders?

Hirschsprung's disease Hirschsprung's disease is an inadequate motility of part of the intestine resulting in a mechanical obstruction.

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

McBurney's point is located by drawing a line from the navel to the right iliac crest. Divide the line into three equal lengths. McBurney's point is midway between the navel to the iliac crest. Pressure over this point will elicit pain in clients with appendicitis.

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child?

Rice Because rice is naturally gluten-free, it is an acceptable food choice for a child who has celiac disease.

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing the client's laboratory values?

WBC 17,000/mm3 The expected reference range for a WBC count for a child is 5,000 to 10,000/mm3. A WBC count of 17,000/mm3 is elevated. The nurse should expect to see an elevated WBC count because appendicitis is an acute bacterial infection.

A nurse is performing gastric lavage on a client using a large bore NG tube. Which of the following actions should the nurse take?

Withdraw fluid until it is clear. The nurse should continue to instill and withdraw the lavage fluid until it is clear.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following findings are associated with this condition?

-Vomiting -Weight loss -Wheezing Vomiting is associated with gastroesophageal reflux. Weight loss is associated with gastroesophageal reflux. Wheezing is associated with gastroesophageal reflux.

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Chrohn's disease. Which of the following information should the nurse include?

Both are inflammatory The nurse should inform the client that both disease processes are an inflammatory process of the gastrointestinal tract.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings?

Place the infant in an infant seat. An infant seat provides elevation and decreases the risk of aspiration.

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

Chronic blood loss A client with long-standing ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occurs over time, although the colitis may result in erosion of the intestine and hemorrhage. These clients often report bloody stools and are therefore at increased risk for developing anemia.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?

History of NSAID use The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse is reviewing the provider's prescription for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?

Insert nasogastric tube. The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus.

A nurse is caring for a 6 month old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the followign fluids should the nurse select for the infant?

Oral electrolyte solution After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance.

A nurse is caring for a 6 week old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect?

Projectile vomiting Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is taking a health history of a client who reports occasionally taking several OTC medications, including H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?

Relief of heartburn Histamine2 receptor antagonists are used to treat duodenal ulcers and prevent their return. In over-the-counter strengths, these medications, such as cimetidine and ranitidine, are used to relieve or prevent heartburn, acid indigestion, and sour stomach.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.

A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

Soy milk Soy milk is the best choice for this client because soy milk is lactose-free.