GI NU102 Exam 1

The nurse working on a medical-surgical floor is caring for a client with a small bowel obstruction that has a nasogastric tube (NG). The unlicensed assistive personnel (UAP) reports to the nurse that the client is reporting nausea and has vomited. What is the correct order of care for this client? All options must be used. 1. Ensure the nasogastric tube is connected to suction. 2. Assess the placement of the nasogastric tube. 3. Assess the client abdomen for bowel sounds. 4. Administer as needed ondansetron. 5. Assess the client's nausea and vomiting. 6. Check the health care provider's orders.

Correct response: "I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

What part of the GI tract begins the digestion of food? 1. Duodenum 2. Esophagus 3. Mouth 4. Stomach

Correct response: "It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

The nurse working on a medical-surgical floor is caring for a client with a small bowel obstruction that has a nasogastric tube (NG). The unlicensed assistive personnel (UAP) reports to the nurse that the client is reporting nausea and has vomited. What is the correct order of care for this client? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Ensure the nasogastric tube is connected to suction. 2Assess the client's nausea and vomiting. 3Assess the client abdomen for bowel sounds. 4Administer as needed ondansetron. 5Check the health care provider's orders. 6Assess the placement of the nasogastric tube.

Correct response: Check the health care provider's orders. Assess the client's nausea and vomiting. Assess the placement of the nasogastric tube. Ensure the nasogastric tube is connected to suction. Assess the client abdomen for bowel sounds. Administer as needed ondansetron. Explanation: The nurse will check the health care provider's orders, assess the client's nausea and vomiting, and assess the placement of the nasogastric tube. The nurse will ensure the nasogastric tube is connected to suction for gastric deflation and then assess the client's abdomen for bowel sounds. Lastly, the nurse should administer as needed ondansetron after the assessments and patency of the NG tube.

The nurse is working with a client that has a gastrostomy tube for enteral nutrition. Which interventions should the nurse use to prevent skin breakdown related to the gastrostomy tube? Select all that apply. Check balloon inflation of the gastrostomy tube weekly. Place a dressing around the site in case of any drainage. Clean the skin around the gastrostomy tube daily. Rotate the gastrostomy tube a quarter turn daily. Use a commercial device to secure the gastrostomy tube.

Correct response: Clean the skin around the gastrostomy tube daily. Rotate the gastrostomy tube a quarter turn daily. Check balloon inflation of the gastrostomy tube weekly. Use a commercial device to secure the gastrostomy tube. Explanation: The gastrostomy tube has a potential for skin breakdown at the site due to skin pressure or irritation. The site should be cleaned daily to stay clean and dry and the gastrostomy tube rotated a quarter turn to prevent pressure to the skin from the tube. If there is drainage, a dressing should be applied; however, it would not be applied if there is no drainage because of the potential for causing pressure and trapping moisture. The balloon needs to be checked and potentially reinflated because if not inflated properly, the tube can move and cause pressure and irritation at the site. The tube needs to be stabilized, and can be with a commercial device, to help keep it from moving and causing irritation.

Which are the important considerations by the nurse before administering feedings to a client through a nasogastric tube? Select all that apply. Flush the tube with 50 mL of water before the feeding to prevent obstruction of the tube. Position the client in the supine position to prevent aspiration. Ensure that anchoring tape is intact. Measure the pH of the aspirated fluid. Determine placement of the tube by aspiration of gastric contents.

Correct response: Determine placement of the tube by aspiration of gastric contents. Measure the pH of the aspirated fluid. Explanation: The most important consideration prior to initiating a tube feeding involves checking placement of the feeding tube. Ensuring aspiration of stomach contents provides evidence that the tube is in the stomach. A more definitive placement check after insertion is to measure the pH of the fluid. Gastric aspirate should be acidic. If the tube is incorrectly situated, there may be a chance of aspiration of contents into the lungs. Anchoring the tube is not the most important consideration. The client should be in high Fowler's position to prevent aspiration, and flushing should be done after the feeding, not before.

The nurse is teaching a client to prevent dumping syndrome after bariatric surgery. Which suggestions will the nurse discuss? Select all that apply. Include a protein with each meal. Eat six small meals a day. Lie down for 15 minutes after a meal. Drink hot tea with each meal. Limit fluids with meals.

Correct response: Eat six small meals a day. Lie down for 15 minutes after a meal. Limit fluids with meals. Include a protein with each meal. Explanation: The nurse will suggest eating six small meals per day, lying down after a meal, limiting fluids and including a protein with each meal to limit dumping syndrome by slowing down stomach emptying. Drinking hot or cold beverages can enhance dumping syndrome.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? 1. "I'll avoid eating or drinking anything 6 to 8 hours before the test." 2. "I'll drink full liquids the day before the test." 3. "I'll take a laxative to clear my bowels before the test." 4. "There is no need for special preparation before the test."

Correct response: Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.

When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first? 1. Percussion 2. Palpation 3. Auscultation 4. Inspection

Correct response: Mouth Explanation: Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.

Which nursing interventions would be appropriate when caring for a client during the first 24 hours after an appendectomy? Select all that apply. Place the client in a semi-Fowler's position. Maintain a clear-liquid diet for 48 hours. Teach the client how to care for the incision. Monitor temperature every 2 hours. Apply an abdominal binder.

Correct response: Place the client in a semi-Fowler's position. Teach the client how to care for the incision. Explanation: Following an appendectomy, the client should be placed in a semi-Fowler's position to relieve tension on the abdomen and the surgical incision and promote comfort. Because the client will likely be discharged within 24 to 48 hours of surgery, teaching the client how to care for the wound is a priority. The client does not need to be limited to a clear liquid diet but may resume a diet as desired following surgery. Although monitoring temperature is important, unless the temperature is elevated, it does not need to be assessed every 2 hours; every 4 hours is sufficient. An abdominal binder is typically not necessary following an appendectomy.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: 1. "It indicates if a cancer is present." 2. "It tells the physician what type of cancer is present." 3. "It determines functionality of the liver." 4. "It detects a protein normally found in the blood."

Correct response: Stomach Explanation: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

The client is admitted with a 2-day history of vomiting and diarrhea, accompanied by abdominal pain. The health care provider diagnoses the client with gastroenteritis. What type of room assignment should the nurse make for this client? Select all that apply. The client should be assigned to a telemetry bed because the client has lost a lot of fluids and is probably dehydrated. The client should be assigned a room near the nurse's desk for close observation. The client should be assigned to a double room with another client having the same diagnosis and the same organism. The client should be assigned to a double room with any other client. The client should be assigned to a single isolation room.

Correct response: The client should be assigned to a double room with another client having the same diagnosis and the same organism. The client should be assigned to a single isolation room. Explanation: The client should be assigned to a single isolation room until three stool samples have come back negative; the client can also be assigned to a room with another client having the same diagnosis and same organism. The client does not need to be on the telemetry unit because of dehydration, nor does the client need to be near the nurse's desk for close observation. The client should not be assigned to a room with another client who has a different diagnosis; this would spread contagious organisms.

A client has early signs of oral cancer. What should the nurse include in a focused assessment? Select all that apply. difficulty swallowing changes in frequency of urination numbness of the tongue an infection or inflammation in the mouth significant weight loss lost the sense of taste

Correct response: an infection or inflammation in the mouth difficulty swallowing significant weight loss numbness of the tongue Explanation: The nurse is conducting a focused assessment of the client's mouth and ability to obtain nutrition. Therefore, the nurse focuses on inspecting the mouth for infection or inflammation, determining if the client has difficulty swallowing and assuring nutrition by noting weight loss. A sign of oral cancer is numbness of the tongue; losing a sense of taste is not an early sign of oral cancer. Urinary output, while important, is not a part of a focused assessment for this health problem.

A nurse is managing the care of a client in a critical care unit. What medication may be used to reduce stress ulcers? Select all that apply. cytoprotective agents antacids aminosalicylates histamine receptor antagonists proton pump inhibitors

Correct response: histamine receptor antagonists proton pump inhibitors cytoprotective agents Explanation: The medications used to reduce stress ulcers are histamine receptor antagonists, proton pump inhibitors, and cytoprotective agents. Amino salicylates and antacids are irritating agents to the gastric mucosa.

A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which additional signs and symptoms? Select all that apply. bleeding fluid and electrolyte imbalance infection respiratory distress weight gain

Correct response: respiratory distress fluid and electrolyte imbalance Explanation: Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure precipitating movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.

A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. What should the nurse do? Select all that apply. Use a higher volume of formula because the formula may be too hypotonic. Change the feeding apparatus every 24 hours. Slow the administration rate. Anticipate changing to a lactose-free formula. Use a diluted formula, gradually increasing the volume and concentration.

You Selected: Slow the administration rate. Anticipate changing to a lactose-free formula. Use a diluted formula, gradually increasing the volume and concentration. Correct response: Change the feeding apparatus every 24 hours. Slow the administration rate. Use a diluted formula, gradually increasing the volume and concentration. Anticipate changing to a lactose-free formula. Explanation: Although about 50% of diarrhea in clients receiving tube feedings is caused by sorbitol-containing medications, the nurse should assess for other possible causes. Diarrhea can occur as a result of bacterial contamination if fresh formula is not used or stored in a refrigerator, or if the feeding apparatus is not changed at least every 24 hours. Lactose intolerance, rapid formula administration, low serum albumin level, and hypertonic solutions may also cause diarrhea. Hypotonic solutions would not be a likely cause of diarrhea, abdominal distention, or cramping.