Chapter 55 Assessment of GI
A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? "Begin a clear liquid diet 12 to 24 hours before the test." "Do not eat or drink anything for 12 hours before the test." "Give yourself tap water enemas until the fluid returns are clear." "You will have to drink a contrast liquid 2 hours before the test."
"Begin a clear liquid diet 12 to 24 hours before the test." Correct: The client is instructed to be on a liquid diet for 12 to 24 hours before a colonoscopy.
Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient GI unit? 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure
40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy Correct: A nurse who has experience with chronic GI problems will have experience and training in instructing clients on colonoscopy preparation.
A nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? "A barium enema every 5 years is a screening option." "I will need to have a routine colonoscopy every 5 years." "My routine flexible sigmoidoscopy every 5 years is OK." "The 'virtual' colonoscopy every 5 years is acceptable."
"I will need to have a routine colonoscopy every 5 years." Correct: The 2010 guidelines indicate that routine screening with colonoscopy is performed every 10 years, not every 5 years. Other options are performed at 5-year intervals.
Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? 32-year-old who needs a nasogastric tube inserted for gastric acid analysis 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography (ERCP) 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes
32-year-old who needs a nasogastric tube inserted for gastric acid analysis Correct: Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.
While working in the outpatient procedure unit, an RN is assigned to these clients. Which client does the nurse assess first? -51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) - 54-year-old who is ready for discharge following a colonoscopy - 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing - 60-year-old with questions about an endoscopic ultrasound examination
51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) Correct: ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status.
A client is admitted to the hospital with elevated serum amylase and lipase levels and a decreased calcium level. Which GI health problem is indicated by these laboratory findings? Acute pancreatitis Cirrhosis Crohn's disease Diarrhea
Acute pancreatitis Correct: These laboratory values are commonly found in clients with acute pancreatitis.
A nurse is assessing a client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? -Asking the client whether he or she has passed flatus (gas) -Auscultating bowel sounds in all abdominal quadrants -Counting the number of bowel sounds in each abdominal quadrant -Observing the abdomen for symmetry and distention
Asking the client whether he or she has passed flatus (gas) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.
A nurse is assessing a client who has come to the emergency department with acute abdominal pain. Which assessment finding is of greatest concern? Bowel sounds are hypoactive in all quadrants. The client reports spasmodic cramping. The client says, "I have not had a bowel movement for 3 days." Bruising is noted around the client's umbilicus.
Bruising is noted around the client's umbilicus. Correct: Bruising around the umbilicus (Cullen's sign) is a sign of intra-abdominal bleeding.
A 49-year-old woman comes to the emergency department (ED) with reports of black tarry stools that started 2 weeks ago. In taking a GI history, which questions does the nurse ask that pertain to Gordon's Functional Health Patterns? Select all that apply. "Are you having any difficulty having sex? How frequently do you have sex?" "Do you have any difficulty chewing or swallowing?" "Do you have pain, diarrhea, gas, or any other problems? Do any specific foods cause these symptoms for you?" "What is your usual bowel elimination pattern? Frequency? Character?" "When was your last colonoscopy?"
Correct: Chewing or swallowing difficulties affect the client's ability to get food into his or GI system. Correct: Pain, diarrhea, gas, and foods that cause these symptoms constitute very important data for collection in the GI history. Correct: The client needs to be questioned about usual bowel elimination patterns-frequency and character are two descriptors. Correct: Colonoscopy history is elicited from the client. Incorrect Feedback: Incorrect: Sexual difficulties and frequency are not generally affected by GI problems. This would not be a routine question in a GI problem inquiry.
Which factors place the client at risk for GI problems? Select all that apply. Eating a high-fiber diet Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct: Smoking or any tobacco use places a client in a higher risk category for GI problems. Correct: Socioeconomic status can influence the risk for GI problems. Clients may not be able to afford to seek care and may put off seeking help. They may not be able to afford treatments or therapeutic diets. Correct: Some herbal preparations contribute to GI problems. Ayurvedic herbs can affect appetite, absorption, and elimination. Correct: NSAIDs can predispose clients to peptic ulcer disease or GI bleeding. Incorrect Feedback: Incorrect: A diet that is high in fiber does not place a client at risk for developing a GI disturbance. High-fiber diets are generally believed to be healthy for most clients.
What is a common GI problem that older adult clients experience more frequently as they age? Decreased hydrochloric acid Excess lipase production Increased liver enzymes Increased peristalsis
Decreased hydrochloric acid Correct: Atrophy of the gastric mucosa causes a decreased ratio of gastrin-secreting cells to somatostatin-secreting cells. This results in a decrease in hydrochloric acid, causing decreased absorption of iron and vitamin B12.
A client with newly diagnosed irritable bowel syndrome (IBS) reports having five to six loose stools daily. What is the common psychological client response to this GI health problem? Acceptance Embarrassment Euphoria Grief
Embarrassment Correct: The client who has a new onset of IBS with frequent stools most likely would be embarrassed
A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation Examines the right upper quadrant (RUQ) of the abdomen last Has the client lie in a supine position with legs straight and arms at the sides Views the abdomen by looking directly down while standing over the client's abdominal area
Examines the right upper quadrant (RUQ) of the abdomen last Correct: The client reports pain in the RUQ, so the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.
A client has a routine sigmoidoscopy. What common complication is the nurse looking for in a postprocedure assessment? Excessive diarrhea Heavy bleeding Nausea and vomiting Severe rectal pain
Heavy bleeding Correct: Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider
Which substance, produced in the stomach, facilitates the absorption of vitamin B12? Glucagon Hydrochloric acid Intrinsic factor Pepsinogen
Intrinsic factor Correct: Parietal cells in the stomach produce intrinsic factor, a substance that facilitates the absorption of vitamin B12. Absence of the intrinsic factor causes pernicious anemia
Which action does the nurse delegate to unlicensed assistive personnel (UAP) helping to care for a client with weight loss and anorexia? Document a nutritional assessment. Lightly palpate the client's abdomen. Monitor the client after endoscopy. Obtain a stool specimen.
Obtain a stool specimen. Correct: Obtaining a stool specimen is a skill included in UAP education and is within the UAP role.
After a colonoscopy, a client reports severe abdominal pain. A nurse obtains these data: temperature 100.2° F (37.9° C), pulse 122, blood pressure 100/45, respirations 44, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? - Give cefazolin (Ancef) 500 mg IV. - Infuse normal saline at 200 mL/hr. -Give morphine sulfate 2 mg IV. -Provide oxygen @ 6 L/min per nasal cannula (N/C)
Provide oxygen @ 6 L/min per nasal cannula (N/C). Correct: Based on the data given, the client may be experiencing complications of colonoscopy such as bleeding or perforation. The most immediate concern involves respiratory status, so the client should be placed on oxygen first.
An outpatient clinic nurse is recovering a client who had a colonoscopy. The client asks for a drink. How does the nurse respond to the client's request? "After I hear bowel sounds, you can have a drink." "Twenty (20) minutes after the procedure was completed, you may have some liquids." "When you are able to pass flatus (gas), you can have a drink." "You can have fluids when you get home and are settled."
When you are able to pass flatus (gas), you can have a drink." Correct: Fluids are permitted after the client's peristalsis has returned. This is validated by the client's passing flatus.