Med-Surg: GI System

A client undergoes a subtotal gastrectomy. After surgery the client begins to hemorrhage. Which clinical findings support the nurse's conclusion that the client is experiencing hypovolemic shock? Select all that apply. One, some, or all responses may be correct. 1. Oliguria 2. Bradypnea 3. Diaphoresis 4. Tachycardia 5. Hypertension

1. Oliguria 3. Diaphoresis 4. Tachycardia

Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct. 1. Tachycardia 2. Hypotension 3. Rigid abdomen 4. Nausea and vomiting 5. Back and shoulder pain

1. Tachycardia 2. Hypotension 3. Rigid abdomen 4. Nausea and vomiting 5. Back and shoulder pain

Which common response do clients with cancer experience, regardless of the site of the cancer, that accounts for their cachexia? 1. Depression precipitates anorexia 2. Changes in taste and food aversions 3. Decreased saliva impedes chewing and swallowing 4. Decreased gastrointestinal absorption of nutrients

2. Changes in taste and food aversions

Which would the nurse identify as a risk factor for hyponatremia? 1. Inadequate fluid intake 2. Drainage from a T-tube 3. Total parenteral nutrition 4. Hypertonic tube feedings

2. Drainage from a T-tube

When assessing a client's abdomen, the nurse palpates directly above the umbilicus. This location is known as which area? 1. Iliac area 2. Epigastric area 3. Hypogastric area 4. Suprasternal area

2. Epigastric area

A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change? 1. Decrease portion size and fat intake. 2. Increase protein and vegetable intake. 3. Decrease carbohydrate and fat intake. 4. Increase fruits and limit fluid intake.

1. Decrease portion size and fat intake.

A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change? 1. Stimulation of the liver to produce an excess quantity of bile pigments 2. Inability of the liver to remove normal amounts of bilirubin from the blood 3. Increased destruction of red blood cells during the acute phase of the disease 4. Decreased prothrombin levels, leading to multiple sites of intradermal bleeding

2. Inability of the liver to remove normal amounts of bilirubin from the blood

A client is admitted to the hospital for the surgical repair of an incarcerated indirect inguinal hernia. Which is the priority preoperative nursing intervention for this client? 1. Placing the client in the supine position 2. Observing the client's bowel movements 3. Monitoring the client's serum enzyme levels 4. Teaching the client about the need to cough postoperatively

2. Observing the client's bowel movements

On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first? 1. Assist the client to ambulate. 2. Obtain the client's vital signs. 3. Administer the prescribed analgesic. 4. Encourage use of the incentive spirometer.

2. Obtain the client's vital signs.

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching? 1. "Before I start the procedure, I will don sterile gloves." 2. "Before I start the procedure, I will obtain my body weight." 3. "Before I start the procedure, I will measure the residual volume." 4. "Before I start the procedure, I will instill 1 oz [30 mL] of a carbonated liquid."

3. "Before I start the procedure, I will measure the residual volume."

A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable? 1. Blue 2. Gray 3. Brick red 4. Dark purple

3. Brick red

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position? 1. Provides the greatest comfort 2. Restores circulating blood volume 3. Helps stop bleeding if any should occur 4. Reduces the fluid trapped in the biliary ducts

3. Helps stop bleeding if any should occur

When preparing a client for a liver biopsy, which instruction would the nurse provide to the client? 1. Turn onto the left side after the procedure. 2. Breathe normally throughout the procedure. 3. Hold the breath at the moment of the actual biopsy. 4. Bear down during the insertion of the biopsy needle.

3. Hold the breath at the moment of the actual biopsy.

The nurse identifies a decrease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for great concern for this client? 1. Calcium 2. Chloride 3. Potassium 4. Phosphate

3. Potassium

Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis? 1. Turkey salad, French fries, sherbet 2. Cottage cheese, mixed fruit salad, milkshake 3. Salad, sliced chicken sandwich, gelatin dessert 4. Cheeseburger, tortilla chips, chocolate pudding

3. Salad, sliced chicken sandwich, gelatin dessert

The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? 1. Gastritis 2. Hiatal hernia 3. Diverticulosis 4. Bowel obstruction

4. Bowel obstruction

The nurse gives a client with hepatitis A information about untoward signs and symptoms related to the disease. The nurse instructs the client to contact the primary health care provider if the client develops which symptom? 1. Fatigue 2. Anorexia 3. Yellow urine 4. Clay-colored stools

4. Clay-colored stools

A client who previously resided in a foreign country has a chronic vitamin A deficiency. Which information about vitamin A would the nurse consider when assessing the client? 1. Vitamin A is an integral part of the retina's pigment called melanin. 2. It is a component of the rods and cones, which control color visualization. 3. Vitamin A is the material in the cornea that prevents the formation of cataracts. 4. It is a necessary element of rhodopsin, which controls responses to light and dark environments.

4. It is a necessary element of rhodopsin, which controls responses to light and dark environments.

The nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis? 1. Fever and malaise 2. Nausea and vomiting 3. Absolute constipation 4. Pain in right lower quadrant

4. Pain in right lower quadrant

The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client?

Permanent sigmoid colostomy When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon (abdominoperineal resection), a permanent colostomy is formed. The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. Temporary double-barrel colostomy is performed to allow a segment of colon to heal; intestinal continuity is restored eventually. Temporary transverse loop colostomy commonly is performed for inflammation of the colon when intestinal continuity eventually can be restored.

A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, You think that it looks repulsive.' The nurse identifies that the client as using which defense mechanism?

Projection Projection is the attribution of unacceptable feelings and emotions onto others. Sublimation is the substitution of socially acceptable feelings or instincts to replace those that are threatening to the ego. Compensation is overachievement in a more comfortable area, thereby covering up a weakness. Intellectualization is the use of mental reasoning processes to deny facing emotions and feelings involved in situation.

Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct. 1. Hematocrit 2. Hemoglobin 3. Platelet count 4. Oxygen saturation 5. Blood urea nitrogen (BUN)

1. Hematocrit 2. Hemoglobin 3. Platelet count 4. Oxygen saturation 5. Blood urea nitrogen (BUN)

A client describes abdominal discomfort after ingestion of milk. Which enzyme, as a result of a genetic deficiency, would the nurse consider to be the cause of the client's discomfort? 1. Lactase 2. Sucrase 3. Maltase 4. Amylase

1. Lactase

During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood? 1. "Meats and cream-based foods need to be refrigerated." 2. "Once most food is cooked, it does not need to be refrigerated." 3. "Poultry should be stuffed and then refrigerated before cooking." 4. "Cooked food should be cooled before being put into the refrigerator."

1. "Meats and cream-based foods need to be refrigerated."

Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease? 1. Esophageal pain may imitate the symptoms of a heart attack. 2. GERD may predispose the client to the development of heart disease. 3. Strenuous exercise may exacerbate reflux problems. 4. Similar laboratory study changes may occur in both problems.

1. Esophageal pain may imitate the symptoms of a heart attack.

A client had surgery for a strangulated hernia. One hour after surgery the client's blood pressure drops from 134/80 to 114/76 mm Hg. Assessment reveals that the client does not have postoperative bleeding. Which action would the nurse take? 1. Place the client in the left side-lying position. 2. Instruct the client to move both legs. 3. Notify the primary health care provider immediately. 4. Administer the prescribed pain medication.

2. Instruct the client to move both legs.

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate? 1. No protein 2. Moderate protein 3. High protein 4. Strict protein restriction

2. Moderate protein

The nurse is providing preoperative teaching to a client who is scheduled for abdominal surgery. The client is fidgeting, slightly diaphoretic, and asking simple questions about information that was already provided during the education session. Which initial step would the nurse take? 1. Repeat the information, speaking slowly and distinctly. 2. Reduce the client's level of anxiety. 3. Teach the client about measures to lessen preoperative anxiety. 4. Ask the client to verbalize concerns and questions.

2. Reduce the client's level of anxiety.

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer? 1. The pain intensifies after vomiting stomach contents. 2. The pain occurs 1 to 2 hours after having a meal. 3. The pain increases when ingesting an excess of fatty foods. 4. The pain begins in the epigastrium and radiates to the abdomen.

2. The pain occurs 1 to 2 hours after having a meal.

When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive? 1. "The other client's infection is not contagious." 2. "This is the usual practice when antibiotic therapy is started." 3. "Placing clients with the same infection in 1 room is safe." 4. "As soon as a private room becomes available, we will move the client."

3. "Placing clients with the same infection in 1 room is safe."

A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors? 1. Men are more likely to be affected than women. 2. Young people are affected more frequently than older people. 3. Individuals who are obese are more prone to this condition than those who are thin. 4. People who are physically active are more apt to develop this condition than those who are sedentary.

3. Individuals who are obese are more prone to this condition than those who are thin.

Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma? 1. Dry, pale pink, and even with the skin 2. Moist, skin-colored, and flush with the skin 3. Moist, red, and raised above the skin surface 4. Dry, purple, and depressed below the skin surface

3. Moist, red, and raised above the skin surface

After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice? 1. Necrosis of the parenchyma caused by the neoplasm 2. Excessive serum bilirubin caused by red blood cell destruction 3. Obstruction of the common bile duct by the pancreatic neoplasm 4. Impaired liver function, resulting in incomplete bilirubin metabolism

3. Obstruction of the common bile duct by the pancreatic neoplasm

The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m2? 1. Obese 2. Normal 3. Overweight 4. Underweight

3. Overweight

The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct. 1. Diarrhea 2. Bradycardia 3. Rebound tenderness 4. Diminished bowel sounds 5. Rigid, boardlike abdomen

3. Rebound tenderness 4. Diminished bowel sounds 5. Rigid, boardlike abdomen

The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select? 1. Levin 2. Dobhoff 3. Salem sump 4. Gastrostomy

3. Salem sump

After a subtotal gastrectomy, a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. Which would the nurse determine is the cause of the latter effect? 1. A second, more extensive rise in glucose 2. An overwhelmed insulin-adjusting mechanism 3. A distention of the duodenum from an excessive amount of chyme 4. An overproduction of insulin that occurs in response to the rise in blood glucose

4. An overproduction of insulin that occurs in response to the rise in blood glucose

A client expresses a complete lack of interest in food. How would the nurse document this finding in the client's medical record? 1. Apathy 2. Aphasia 3. Adactyly 4. Anorexia

4. Anorexia

A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function? 1. Blood clotting 2. Bone formation 3. Muscle contraction 4. Cellular membrane structure

4. Cellular membrane structure

A client had a pancreaticoduodenectomy for cancer of the pancreas. The nurse provides education about long-term complications related to this type of surgery, including information about hypoinsulinism. The nurse would instruct the client to report which symptom that may be indicative of the complication? 1. Oliguria 2. Anorexia 3. Weight gain 4. Increased thirst

4. Increased thirst

The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step?

Assess barriers to learning colostomy care. Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention?

Observe the client for increasing confusion. An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affec the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.