Chapter 43: Assessment: Gastrointestinal System Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

A patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by assistive personnel (AP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with a wet cloth

ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the AP are appropriate. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX: Safe and Effective Care Environment

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action would the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO. DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Implementation MSC:NCLEX: PhysiologicalIntegrity

The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information would the nurse communicate to the health care provider before preparing the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination.

ANS: A If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure would be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance

A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient has a gastrostomy tube. b. The patient ate a bagel 4 hours ago. c. The patient took a laxative the day before. d. The patient had a high-fat meal the previous evening.

ANS: B Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient would be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX: PhysiologicalIntegrity

The nurse is caring for a patient with a biliary obstruction. Which condition would the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level

ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction. DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess: Planning

Which action would the nurse take after assisting with a needle biopsy of the liver at a patient's bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient's post biopsy coagulation studies. d. Position a sandbag over the liver to provide pressure.

ANS: B After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX: PhysiologicalIntegrity

An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding would the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area

ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: PhysiologicalIntegrity

Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. b. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.

ANS: B The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver. DIF:CognitiveLevel: Understand (Comprehension) TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance

The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most useful initial question? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"

ANS: B This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question. DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance

Which area of the abdomen will the nurse palpate to assess for splenomegaly? A. RUQ B. LUQ C. RLQ D. LLQ

ANS: B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen. DIF:CognitiveLevel: Understand (Comprehension) TOP: NursingProcess: Assessment MSC:NCLEX: Health Promotion and Maintenance

While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). Which area of patient knowledge would the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors

ANS: C FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP. DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: Health Promotion and Maintenance TOP: NursingProcess: Planning

A patient has arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The patient's temperature is 101.4F. d. The patient's pulse rate is 100 beats/min.

ANS: C A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment MSC:NCLEX: PhysiologicalIntegrity

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Intermittent sounds

ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. Normal sounds are relatively high pitched intermittent gurgling. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: PhysiologicalIntegrity

An older patient reports chronic constipation. When would the nurse suggest that the patient regularly attempt defecation? a. Right after awakening in the morning b. Before eating breakfast c. Immediately after the first daily meal d. Right before bedtime

ANS: C The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of eating, and bedtime timing do not stimulate these reflexes. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Implementation MSC:NCLEX: PhysiologicalIntegrity

Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food

ANS: C Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss. DIF:CognitiveLevel: Analyze (Analysis) TOP: NursingProcess: Assessment MSC:NCLEX: PhysiologicalIntegrity

6. Which statement by a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I take an antacid for indigestion several times a week" d. "I use acetaminophen (Tylenol) every 4 hours for pain."

ANS: D Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education. DIF:CognitiveLevel: Apply (Application) TOP: NursingProcess: Assessment MSC:NCLEX: PhysiologicalIntegrity

3. Which condition would the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency

ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation. DIF:CognitiveLevel: Apply (Application) MSC:NCLEX: PhysiologicalIntegrity TOP: NursingProcess: Planning