TEST 2: Gastrointestinal System Mastering (Med-Surg)

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective?

A. "Before I start the procedure, I will don sterile gloves." B. "Before I start the procedure, I will obtain my body weight." *C. "Before I start the procedure, I will measure the residual volume." D. "Before I start the procedure, I will instill one ounce (30 mL) of a carbonated liquid." RATIONALE: Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely. TEST-TAKING TIP: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?

*A. Sodium and chloride levels B. Bicarbonate and sulfate levels C. Magnesium and protein levels D. Calcium and phosphate levels RATIONALE: Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow?

*A. Add extra salt to food B. Consume high-potassium foods C. Omit protein foods at each meal D. Restrict the daily intake of fluids to 1 L RATIONALE: Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease. TEST-TAKING TIP: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history?

A. Any rectal cancer in the family *B. All foods eaten in the past 24 hours C. Any recent extreme emotional stress D. An upper respiratory infection in the past 10 days RATIONALE: The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel?

A. Apply insect repellent. *B. Drink only bottled water. C. Avoid drinking pasteurized milk. D. Obtain vaccine prior to foreign travel. RATIONALE: Entamoeba histolytica, the organism that causes amebic dysentery, is transmitted through excreta; bottled water prevents consumption of water that may be contaminated by the causative microorganism. Amebic dysentery is not a mosquito- or tick-borne disease. Pasteurization kills microorganisms that can cause disease. Vaccines do not prevent amebic dysentery.

When assessing a client's abdomen, the nurse palpates the area directly above the umbilicus. By what term is this area known?

A. Iliac area *B. Epigastric area C. Hypogastric area D. Suprasternal area RATIONALE: The stomach is located within the sternal angle, known as the epigastric area. The iliac area is in the area of the iliac bones. The hypogastric area is the lowest middle abdominal area. The suprasternal area is the area above the sternum.

A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have?

A. Single-lumen; for gastric lavage B. Double-lumen; for intestinal decompression *C. Triple-lumen; for esophageal compression D. Multilumen; for gastric and intestinal decompression RATIONALE: The Sengstaken-Blakemore is a triple-lumen tube; one lumen inflates the esophageal balloon that compresses the esophagus, the second inflates the gastric balloon, and the third is attached to suction to decompress the stomach. The Sengstaken-Blakemore is not a single-lumen tube. The Sengstaken-Blakemore is not a double-lumen tube; the stomach, not the intestine, is decompressed. The intestine is not decompressed with a Sengstaken-Blakemore tube.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period?

A. Limiting fluid intake for several days B. Withholding fluids for 72 hours C. Having the client change the colostomy bag *D. Keeping the client's skin around the stoma clean RATIONALE: If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection. Although oral fluids are withheld until peristalsis returns, it is essential that parenteral fluids be administered to replace the losses incurred by surgery. The client is often unable to accept the altered body image and must be given time to adjust before participating actively in self-care. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome?

A. Low-residue, bland diet B. Fluid intake below 500 mL *C. Small, frequent feeding schedule D. Low-protein, high-carbohydrate diet RATIONALE: Small feedings reduce the amount of bulk passing into the jejunum and therefore reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair. TEST-TAKING TIP: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted?

A. Supine B. Mid-Fowler *C. High-Fowler D. Trendelenburg RATIONALE: The high-Fowler position promotes optimal entry into the esophagus aided by gravity. Supine position does not take full advantage of the effect of gravity. Mid-Fowler and Trendelenburg positions will contribute to aspiration. The head of the bed should be raised, not lowered.