MEDSURG - GI Review (2)

List the correct order in which to apply an ostomy pouch: 1. Remove the used pouch and skin barrier 2. Perform hand hygiene, and apply clean gloves. 3. Asses the stoma for color, swelling, and healing. 4. Gently cleanse the preistomal skin with warm tap water. 5. Apply nonallergenic tape around the pectin skin barrier. 6. Cut an opening on the pouch 1/16 inch larger than the stoma. 7. Press the adhesive backing of the pouch smoothly against the skin.

2, 1, 3, 4, 6, 5, 7

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? a. "I will be able to regulate when I have stools." b. "I will be able to wear the pouch until it leaks." c. "Dried fruit and popcorn must be chewed very well." d. "The drainage from my stoma can damage my skin."

A ("I will be able to regulate when I have stools." The ileostomy is in the ileum and drains liquid stool frequently, unlike the colostomy which has more formed stool the further distal the ostomy is in the colon. The ileostomy pouch is usually worn 4-7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.)

After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: a. Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection b. Nothing can be done about the concerns of odor with the appliance. c. Ordering appliances through the client's health care provider d. The appliance will not be needed when traveling

A (Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection Signs and symptoms for monitoring infection at the ostomy site are a priority evaluation for clients with new ostomies. The remaining actions are not appropriate. There are supplies available for clients to help control odor that may be incurred because of the ostomy. Although a prescription for ostomy supplies is needed, you can order the supplies from any medical supplier. Dependent on the location and trainability of the ostomy, appliances are almost always worn throughout the day and when traveling.)

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? a. Polyps b. Weight gain c. Hemorrhoids d. Duodenal ulcers

A (Polyps Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren't preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.)

The wound, ostomy nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? a. The patient must be able to see the site. b. Outside the rectus muscle area is the best site. c. It is easier to seal the drainage bag to a protruding area. d. The ostomy will need irrigation, so area should not be tender.

A (The patient must be able to see the site. In selection of the ostomy site, the nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag.)

A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last: a. Assist with ambulation to promote peristalsis b. Administer Ringer's Lactate c. Insert a nasogastric tube. d. Start and infusion of hyperalimentation fluids.

A, B, C, D (The nurse should first help the client ambulate to try to induce peristalsis; this may be effective and require the least amount of invasive procedures. I.V. fluid therapy can be done to correct fluid and electrolyte imbalances (sodium and potassium), and normal saline or Ringer's Lactate to correct interstitial fluid deficit. Nasogastric (NG) decompression of G.I. tract to reduce gastric secretions and nasointestinal tubes may also be used. Hyperalimentation can be used to correct protein deficiency from chronic obstruction, paralytic ileus, or infection)

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). The nurse performs the following actions while the client receives PN (select all that apply): a. Document intake and output. b. Use clean technique for all catheter dressing changes. c. Weigh the client every day. d. Cover insertion site with a transparent dressing that is changed daily. e. Check blood glucose level every 6 hours.

A, C, E (A) Document intake and output; C) Weigh the client every day; E) Check blood glucose level every 6 hours When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes.)

The nurse teaches clients with a new colostomy that they can eat whatever roods they like but that which of the follwing foods typically produce gas and should be consumed cautiously? (Select all that apply? ) a. Pasta b. Beans c. Garlic d. Onions e. Cauliflower

B, D, E

A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply. a. Projectile vomiting. b. Significant abdominal distention. c. Copious diarrhea. d. Rapid onset of dehydration. e. Increased bowel sounds.

A, D, E (Signs and symptoms of intestinal obstructions in the small intestine may include projectile vomiting and rapidly developing dehydration and electrolyte imbalances. The client will also have increased bowel sounds, usually high-pitched and tinkling. The client would not normally have diarrhea and would have minimal abdominal distention. Pain is intermittent, being relieved by vomiting. Intestinal obstructions in the large intestine usually evolve slowly, produce persistent pain, and vomiting is less common. Clients with a large-intestine obstruction may develop obstipation and significant abdominal distention.)

The nurse identifies that which patient is at highest risk for developing colon cancer? a. A 28-year-old male who has a body mass index of 27 b. A 32-year-old female with a 12-year history of ulcerative colitis c. A 52-year-old male who has followed a vegetarian diet for 24 years d. A 58-year-old female taking prescribed estrogen replacement therapy

B (A 32-year-old female with a 12-year history of ulcerative colitis Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years) Obesity (body mass index ≥ 30 kg/m2) Family (first-degree relative) or personal history of colorectal cancer Adenomatous polyposis Red meat (=7 servings/week) Cigarette use Alcohol (=4 drinks/week).)

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? a. Maintaining wrinkles in the faceplate so it doesn't irritate the skin b. Gently washing the area surrounding the stoma using a facecloth and warm water c. Scrubbing fecal material from the skin surrounding the stoma d. Cutting the faceplate opening no more than 2" larger than the stoma

B (Gently washing the area surrounding the stoma using a facecloth and warm water For a client with an ostomy, maintaining skin integrity is a priority. The nurse should gently wash the area surrounding the stoma using a facecloth warn water. Scrubbing the area around the stoma can damage the skin and cause bleeding. The faceplate opening should be no more than 1/8" to 1/6" larger than the stoma. This size protects the skin from exposure to irritating fecal material. The nurse can create an adequate seal and prevent leakage of fecal material from under the faceplate by applying a thin layer of skin barrier and smoothing out wrinkles in the faceplate. Eliminating wrinkles in the faceplate also protects the skin surrounding the stoma from pressure.)

The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate? a. Reassure the client that the nasoenteric tube is functioning. b. Assess the client for a rigid abdomen. c. Administer an opioid as ordered. d. Reposition the client on the left side.

B (The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain.)

A 24-year-old athlete is admitted to the trauma unit following a motor-vehicle collision. The client is comatose and has developed ascites as a result of the accident. You are explaining the client's condition to his parents. In your education, what do you indicate is the primary function of the small intestine? a. Digest proteins b. Digest fats c. Absorb nutrients d. Absorb water

C (Absorb nutrients The primary function of the small intestine is to absorb nutrients from the chyme.)

Which of the following terms is used to refer to intestinal rumbling? a. Diverticulitis b. Tenesmus c. Borborygmus d. Azotorrhea

C (Borborygmus Borborygmus is the intestinal rumbling that accompanies diarrhea. Tenesmus is the term used to refer to ineffectual straining at stool. Azotorrhea is the term used to refer to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.)

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the: a. rectum. b. stomach. c. small intestine. d. large intestine.

C (Small intestine. The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.)

A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a. Instruct the patient to keep a record of food intake b. Instruct the patient to avoid prune or apple juice c. Suggest fluid intake of at least 2 L per day d. Assist the patient regarding the correct diet or to minimize food intake

C (Suggest fluid intake of at least 2 L per day. For constipation the nurse should suggest a fluid intake of at least 2L per day. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the patient to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the patient to keep a record of food intake in case of diarrhea because this helps identify specific foods that irritate the GI tract.)

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? a. The stoma extends 1/2 in. above the abdomen. b. The skin under the appliance looks red briefly after removing the appliance. c. The stoma color is dusky (purple) d. An ascending colostomy delivers liquid feces.

C (The stoma color is a dusky (purple) An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.)

As the nurse prepares to assist Mrs. P with her newly created Ileostomy, She is aware of which of the following? a. An appliance will not be required on the continual basis b. The size of the stoma stabilizes within two weeks c. Irrigation is necessary for regulation d. Fecal drainage will be liquid

D (Fecal drainage will be liquid And appliance is usually required on a continual basis because the fecal drainage is liquid. Stomas size usually stabilizes within 4 to 6 weeks, and Ileostomy Irrigation is not necessary because fecal matter is liquid.)

The nurse is caring for a 68-year-old patient admitted with abdominal pain, nausea, and vomiting. The patient has an abdominal mass, and a bowel obstruction is suspected. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture? a. Low-pitched and rumbling above the area of obstruction b. High-pitched and hypoactive below the area of obstruction c. Low-pitched and hyperactive below the area of obstruction d. High-pitched and hyperactive above the area of obstruction

D (High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high-pitched, sometimes referred to as "tinkling" above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.)

The colon's three main functions include which one of the following in addition to that of fecal elimination? a. To eliminate excess fluid b. To excrete excess electrolytes with the fecal matter c. Excretion of a substance that sloughs off dead cells d. To excrete mucus and protect the intestine from bacteria

D (To excrete mucus and protect the intestine from bacteria The colon's main functions are the absorption of water and electrolytes, the mucal protection of the intestinal wall, and fecal elimination.)