MEDSURG Prepu: Chapter 44: Introduction to the Gastrointestinal System and Accessory Structures
A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?
Correct response: "Abdominal ultrasound poses no known safety risks of any kind." Explanation: An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy.
A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make?
Correct response: "Changes in the mouth can help explain why your condition is occurring." Explanation: A complete assessment of the oral cavity is essential because many disorders, such as cancer, diabetes, and immunosuppressive conditions resulting from medication therapy or acquired immunodeficiency syndrome, may be manifested by changes in the oral cavity, including stomatitis. Assessment of the mouth is not done because it is the body part least examined. It is not assessed because it is a part of every assessment. The nurse has no way of knowing if the client's gastrointestinal problem is in the client's mouth.
A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client?
Correct response: "Do not take any NSAIDs within 72 hours of the test." Explanation: In the past, clients were advised to avoid ingesting red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish for 72 hours prior to the study because it was thought that these were associated with false-positive results; likewise, clients were advised to avoid ingesting vitamin C from supplements or foods as it was believed that this was associated with false-negative results. However, these restrictions are no longer advised as their actual effects on test results have not been established; plus, they unnecessarily restricted client participation in screening.
A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client?
Correct response: "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." Explanation: 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.
The nurse just completed educating a client on hearing aid care. Which statement by the client indicates that the teaching was effective?
Correct response: "I will use a small pipe cleaner to clean the cannula on the hearing aid." Explanation: The cannula on the hearing aid should be cleaned with a small pipe cleaner or pipe cleaner-like object. Only the ear mold should be cleaned daily using soap and water; no other part of the hearing aid should be cleaned with soap and water. The client should be taught to troubleshoot if the hearing aid whistles. Many times the client can fix the issue when this happens. The ears should not be dried using a cotton-tipped applicator because it can cause trauma and lead to otitis externa.
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?
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.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:
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 is caring for a client scheduled for a diagnostic laparoscopy. The client has questions regarding the use of anesthetic during the procedure. Which response will the nurse provide the client?
Correct response: "Let me have the primary health care provider explain this again to you." Explanation: To ensure the client is aware of the details of the procedure it would be imperative that the surgeon speak to the client. It is out of the scope of practice for the nurse to discuss the details of the surgical procedure if the client is confused about it. If the client is asking any question it is important to give the best answer as soon as possible. It is clear the client wants to discuss the procedure so the nurse would not need to ask any further open ended questions to gather data.
A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation?
Correct response: "You'll need to have enemas the day before the test." Explanation: Preparation of the client 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.
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond?
Correct response: "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." Explanation: The appendix is an appendage of the cecum (not the small intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.
It is suspected that a client might have a problem in the duodenum and the client is scheduled to have GI studies done in the morning. In client education, the nurse describes the procedure and includes basic information about anatomy and the function of the organs involved. The client asks how long the duodenum is. What is the nurse's best response?
Correct response: 10 inches Explanation: The duodenum is approximately 10 inches long and is the first region of the small intestine.
What is the approximate length of the large intestine?
Correct response: 4-5 feet Explanation: The large intestine, approximately 4 to 5 feet long and 2 inches in diameter, receives waste from the small intestine and propels waste toward the anus, the opening from the body for elimination.
Which of the following is the primary function of the small intestine?
Correct response: Absorption Explanation: Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.
Which of the following digestive enzymes aids in the digesting of starch?
Correct response: Amylase Explanation: 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. Bile is secreted by the liver and is not considered a digestive enzyme.
A nurse is caring for a client with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client?
Correct response: Apply local anesthetic to the back of the client's throat. Explanation: Preparation includes spraying or gargling with a local anesthetic. A nasogastric tube or a micro Fleet enema is not required for this procedure. The client should be positioned in a side-lying position in case of emesis.
High doses of which medication can produce bilateral tinnitus?
Correct response: Aspirin Explanation: At high doses, aspirin toxicity can produce bilateral tinnitus. Meclizine and dimenhydrinate are used for nausea and vomiting related to motion sickness. Antiemetics, such as promethazine suppositories, help control nausea and vomiting and vertigo through an antihistamine effect.
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
Correct response: Avoiding the use of cotton swabs Explanation: Nurses should instruct clients not to clean the external auditory canal with cotton-tipped applicators and to avoid events that traumatize the external canal such as scratching the canal with the fingernail or other objects. Environmental noise should be avoided, but this does not address the risk for ear infection. Routine use of antibiotics is not encouraged and rinsing the ears after swimming is not recommended.
Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity?
Correct response: Be aware of clients' medication regimens and collaborate with other professionals accordingly. Explanation: A variety of medications may have adverse effects on the cochlea, vestibular apparatus, or cranial nerve VIII. All but a few, such as aspirin and quinine, cause irreversible hearing loss. Ototoxicity is not related to age-related changes, noise exposure, or the differences between types of hearing loss.
The physician suggests that a client use meclizine as treatment for his motion sickness. The nurse explains the rationale for this drug based on an understanding of which of the following as the drug's action?
Correct response: Blocks conduction of the vestibular pathways Explanation: Meclizine blocks the conduction of the vestibular pathway in the inner ear to provide some relief of nausea and vomiting. Anticholinergic agents, such as scopolamine, antagonize the histamine response. Meclizine does not depress the central nervous system. Diuretics help to lower the pressure of the endolymphatic system in Meniere's disease.
A client reports a history of bleeding hemorrhoids to the nurse. Which observation supports the client's statement?
Correct response: Blood streaks on stool Explanation: Blood in the stool can present in various ways and must be investigated. 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. Hard, dry stool occurs in constipation. If blood is shed in sufficient quantities into the upper GI tract, it produces a dark red color, a tarry-black color, or melena.
During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?
Correct response: Bowel perforation Explanation: Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs).
A hearing-impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client?
Correct response: Client is likely unable to hear the nurse during test. Explanation: During health care and screening procedures, the practitioner (e.g., dentist, health care provider, nurse) must be aware that clients who are deaf or hearing impaired are unable to read lips, see a signer, or read written materials in the dark rooms required during some diagnostic tests. The same situation exists if the practitioner is wearing a mask or not in sight (e.g., x-ray studies, MRI, colonoscopy).
A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?
Correct response: Colonoscopy Explanation: 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.
An initial, convenient assessment of an older adult client's complaint of hearing loss would be inspection, using an otoscope, for the presence of impacted cerumen. Which of the following is a primary cause of an external ear disorder in the elderly?
Correct response: Conduction problem Explanation: Conductive hearing loss usually results from an external ear disorder, such as impacted cerumen, or a middle ear disorder, such as otitis media or otosclerosis. In such instances, the efficient transmission of sound by air to the inner ear is interrupted.
A client is newly diagnosed with benign paroxysmal positional vertigo. Which is the priority nursing intervention?
Correct response: Encourage bed rest. Explanation: Bed rest is recommended for clients with acute symptoms. Best rest can ease the symptoms while keeping the client safe. Epley/canalith repositioning procedures may be used to resolve attacks of vertigo. The client will usually vomit and may need to be medicated with an antiemetic before the procedure can be tried. Clients with acute vertigo may be medicated with meclizine for 1 to 2 weeks, but because safety is a concern, encouraging bed rest would be the highest priority. Balance exercises would not be taught until the acute symptoms have eased. These exercises will help the brain compensate for the vestibular disorder.
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
Correct response: Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.
The nurse is investigating a client's report of pain in the duodenal area. Where should the nurse perform the assessment?
Correct response: Epigastric area and consider possible radiation of pain to the right subscapular region Explanation: Indigestion is an imprecise term that refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation; it occurs in approximately 25% of the adult population (Harmon & Peura, 2010).
An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?
Correct response: Fluids must be increased to facilitate the evacuation of the stool. Explanation: Postprocedural client education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements. The number of bowel movement is noted 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 client is having a colonic transit study to diagnose a gastrointestinal disorder. Which instruction will the nurse provide to the client after taking a capsule containing radionuclide markers?
Correct response: Follow a regular diet and usual daily activities. Explanation: Colonic transit studies are used to evaluate colonic motility and obstructive defecation syndromes. The client is given a capsule containing 20 radionuclide markers and instructed to follow a regular diet and usual daily activities. There is no reason for the client to follow a clear liquid diet, take over-the-counter laxatives, maintain nothing by mouth status, take oral medications, eat a low-fat diet, or take proton pump inhibitor medications.
The nurse is caring for a client with a gastrointestinal condition. For which reason will the nurse question the client being scheduled for a barium enema?
Correct response: Frank blood in stool Explanation: Barium enemas may be contraindicated for specific conditions. One of these is active gastrointestinal bleeding as this would prohibit the use of laxatives and enemas. A barium enema would be indicated for a history of polyps, to diagnose bowel malfunction such as constipation, and to detect tumors or other lesions of the large intestine.
A nurse is assessing the abdomen of a client just admitted to the unit with suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding?
Correct response: GI diseases often produce skin changes. Explanation: 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.
A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT?
Correct response: Hemorrhoids Explanation: 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 client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause?
Correct response: Hemorrhoids Explanation: 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 client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test?
Correct response: History of allergies Explanation: A CT scan provides cross-sectional images of abdominal organs and structures. A CT scan may be performed with or without oral or intravenous (IV) contrast, but the enhancement of the study is greater with the use of a contrast agent. A common risk from IV contrast agents is allergic reactions; therefore, the client must be screened for this risk. Any allergies to contrast agents, iodine, or shellfish must be determined before administration of a contrast agent. Clients allergic to the contrast agent may be premedicated with a corticosteroid and antihistamine. Therefore, a history of allergies must be completed before the test. Assessing for the presence of a cochlear implant is recommended before magnetic resonance imaging (MRI), but not before a CT scan. The last use of an oral laxative and current list of prescribed medications are not required before a CT scan of the abdomen.
The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?
Correct response: Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. 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, but these assessments are highly subjective (Li, Wang, & Ma, 2012).
A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds?
Correct response: Hypoactive Explanation: 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 client has undergone a myringotomy. The nurse interprets this as which of the following?
Correct response: Incision of the eardrum Explanation: A myringotomy refers to an incision of the tympanic membrane. Ventilation tubes may be inserted after a myringotomy. Tympanoplasty refers to the surgical reconstruction of the eardrum. Ossiculoplasty refers to the surgical reconstruction of the middle ear bones.
A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery?
Correct response: Increase fluid intake to evacuate the barium. Explanation: Adequate fluid intake is necessary to rid the GI tract of barium. The client 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.
A nurse is caring for a client who is scheduled for a colonoscopy and whose 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?
Correct response: Inflammatory bowel disease Explanation: The use of a lavage solution is contraindicated in clients with intestinal obstruction or inflammatory bowel disease. It can safely be used with clients who have polyps, colon cancer, or diverticulitis.
The nurse is caring for a client who has a diagnosis of AIDS. Inspection of the client's mouth reveals the new presence of white lesions on the client's oral mucosa. What is the nurse's most appropriate response?
Correct response: Inform the primary provider of this finding. Explanation: The nurse should inform the primary provider of this abnormal finding in the client's oral cavity, since it necessitates medical treatment. It would be inappropriate to try to remove skin lesions from a client's mouth and salt water will not resolve this problem, which is likely due to candidiasis. A dietitian referral is unnecessary.
The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow?
Correct response: Inspection, auscultation, percussion, and palpation Explanation: When performing a focused assessment of the client'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 client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?
Correct response: Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.
The nurse is planning the care of a client who is adapting to the use of a hearing aid for the first time. What is the most significant challenge this client is likely to experience?
Correct response: Learning to cope with amplification of background noise Explanation: Each of the answers represents a common problem experienced by clients using a hearing aid for the first time. However, amplification of background noise is a difficult problem to manage and is the major reason why clients stop using their hearing aid. All clients learning to use a hearing aid require support and coaching by the nurse and other members of the health care team. Clients should be encouraged to discuss their adaptation to the hearing aid with their audiologist.
A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis.
Correct response: Left upper Explanation: The pancreas, which is about 6 inches long, is located behind the stomach in the upper left side of the body.
While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?
Correct response: Liver Explanation: The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.
A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow?
Correct response: Medulla oblongata Explanation: 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.
What part of the GI tract begins the digestion of food?
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.
The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?
Correct response: Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.
An advanced practice nurse is assessing the size and density of a client's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?
Correct response: Percussion Explanation: 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 client 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?
Correct response: Persistently low hemoglobin and hematocrit Explanation: 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.
Results of a client's preliminary assessment prompted an examination of the client's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding?
Correct response: Prepare to meet the client's psychosocial needs. Explanation: 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 client would likely be learning that he or she has cancer, so the nurse must prioritize the client's immediate psychosocial needs, not abdominal assessment. Future screening is not a high priority in the short term.
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
Correct response: Red Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium.
A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client's health issues?
Correct response: Stomach emptying takes place more slowly. Explanation: 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 client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider?
Correct response: Streaks of blood present in the stool Explanation: 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 client to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify accordingly.
The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract?
Correct response: The absorption into the bloodstream of nutrient molecules produced by digestion Explanation: 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.
A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education?
Correct response: The client can resume a normal routine immediately. Explanation: Following sigmoidoscopy, clients can resume their regular activities and diet. There is no need to push fluids and neither fecal urgency nor rectal bleeding is expected.
A medical client's CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding?
Correct response: The client may have cancer, but other GI disease must be ruled out. Explanation: CA 19-9 levels are elevated in most clients 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.
The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?
Correct response: To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.
A nurse is caring for a client with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client?
Correct response: Upper GI tract Explanation: 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 nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?
Correct response: Upper GI tract Explanation: 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 client who has been in a motor-vehicle collision is comatose and has developed ascites as a result of the accident. The nurse explains the condition to the client's family, and indicates that the primary function of the small intestine is to:
Correct response: absorb nutrients Explanation: The primary function of the small intestine is to absorb nutrients from the chyme.
The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?
Correct response: clear liquids day before Explanation: The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.
A client is scheduled to have an endoscopic retrograde cholangiopancreatography. Which structures are visualized during this procedure?
Correct response: common bile duct, pancreatic duct, and biliary tree Explanation: With the use of endoscopy, dye is injected through a catheter into the common bile duct and the pancreatic duct, permitting visualization and evaluation of the biliary tree. The common bile duct, the pancreatic duct, and the biliary tree are visualized.
When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported?
Correct response: duodenal ulcer Explanation: Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.
Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?
Correct response: duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.
Which response is a parasympathetic response in the GI tract?
Correct response: increased peristalsis Explanation: Increased peristalsis is a parasympathetic response in the GI tract. Decreased gastric secretion, blood vessel constriction, and decreased motility are sympathetic responses in the GI tract.
The nurse performs an abdominal assessment. The nurse should perform the assessment in which order?
Correct response: inspection, auscultation, percussion, palpation Explanation: The correct order for the abdominal assessment is inspection, auscultation, percussion, and palpation.
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are
Correct response: normal. Explanation: Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.
An enzyme that begins the digestion of starches is
Correct response: ptyalin. Explanation: Ptyalin, or salivary amylase, is an enzyme that begins digestion of starches. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. Bile is an enzyme secreted by the liver and gallbladder.
A client tells the nurse that the stool was colored yellow. The nurse assesses the client for
Correct response: recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.
Which procedure is performed to examine and visualize the lumen of the small bowel?
Correct response: small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.
The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?
Correct response: upper GI enteroclysis Explanation: Enteroclysis is a double contrast study where a duodenal tube is inserted and 500 to 1000 mL of thin barium sulfate suspension and then methylcellulose is infused. Fluoroscopy is used to visualize the filling of the intestinal loops over a period of up to 6 hours. The test is used for detection of small bowel obstruction and diverticuli. Abdominal ultrasound, magnetic resonance imaging, and positron emission tomography do not involve insertion of a duodenal tube.
The nurse recognizes which change of the GI system is an age-related change?
Correct response: weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.
A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test?
Ingest nothing by mouth after midnight. Explanation: An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent such as barium. To prepare for the test, the client should be instructed to ingest nothing after midnight before the test. Clear liquids are not permitted the morning of the test. Most oral medications are withheld the morning of the test, but not for 24 hours before. There is no reason to avoid products containing aspirin for a week before the test.
