MOC 3 GI ATI

A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube to the client, which of the following findings should the nurse anticipate?

"Coffee-ground" drainage or emesis indicates the presence of blood. The coffee ground appearance is the result of the effects of methemoglobin on the hemoglobin.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect?

A paralytic ileus in a postoperative client is indicated by the absence of bowel sounds, abdominal distention, and the client passing no stool or flatus. It is often caused by bowel handling during surgery and opioid analgesic use.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.

A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice?

According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.

A nurse prepared to replace the nearly empty container of TPN for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Administering an infusion of 10% dextrose will prevent hypoglycemia.

A nurse is caring for four client on a medical-surgical unit. Which of the following clients should the nurse assess first?

After removal of an indwelling urinary catheter, the client should void within 4 hr. If the client has not voided in 4 hr, the nurse may need to reinsert the catheter; therefore, when using the priority-setting framework of urgent vs. nonurgent, this client should be assessed first because he has not voided for 5 hr.

A nurse is caring for a client who came to the ED with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working.

A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?

Decreased bowel motility is an adverse effect of anesthesia. The nurse should encourage the client to ambulate and increase fiber intake as prescribed to promote a return of bowel function and reduce the risk for paralytic ileus.

A nurse is preparing to administer an enteral feeding via NG tube. Identify the correct sequence the nurse should follow to initiate the feeding.

First, the nurse should verify tube placement. Second, the nurse should check the residual feeding contents and follow agency protocol about reinstilling the contents into the stomach. Third, the nurse should administer the feeding, followed by evaluation of the client's tolerance to the feeding.

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

Ham is high in sodium and can increase fluid retention, leading to edema. Clients who have cirrhosis are prone to edema as the osmotic pressures change due to a decrease in plasma albumin and are placed on low-sodium diets.

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

Laxatives are contraindicated in clients who have fecal impaction, bowel obstruction, and acute abdominal surgery to prevent perforation. Because the bowel does not allow for any passage of stool with a complete small bowel obstruction, laxatives will cause increased abdominal cramping and discomfort.

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Measuring the client's orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that client's peristalsis is returning?

Passing flatus and belching indicate the return of peristaltic activity.

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority?

Providing fluid to the client will restore circulating volume and increase blood pressure.

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?

Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis.

A nurse is assessing a client who is receiving TPN. Which of the following findings should the nurse recognize as a complication of this therapy?

TPN contains a high concentration of dextrose, which can result in hyperglycemia.

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?

The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days.

A nurse is caring for a client following an EGD procedure. Which of the following assessments is the nurse's priority?

The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

The nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse is reviewing the provider's prescriptions for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?

The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus.

A nurse is teaching a client who has a prescription of a NG tube to treat a pyloric obstruction. Which of the following rationales for the use of the NG tube should the nurse include in the teaching?

The nurse should inform the client that because the stomach is dilated and may contain undigested food, it must be decompressed, necessitating the placement of an NG tube.

A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?

The nurse should inform the client that the NG tube will decompress the stomach of gas and fluid in order to allow the bowel to rest.

A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?

The nurse should recommend the client rest frequently throughout the day to reduce the metabolic demands upon the liver and decrease energy demands.

A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care?

The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client's risk for increased fluid retention.

A nurse is planning care for a client who is to start receiving TPN. Which of the following interventions should the nurse include in the plan of care?

The nurse should use a 1.2 micron filter when infusing TPN with fat emulsion added to filter out any precipitate that is too large to pass through the filter. The nurse should limit the lipid infusion to 12 hr to prevent colonization of microorganisms. The nurse should plan to change the TPN infusion tubing every 24 hr to prevent infection.

A nurse is caring for a client who has bleeding esophageal varices and is being treated with an Sengstaken-Blakemore tube. Which of the following actions should the nurse perform?

While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction.

A nurse admits a client to the ED who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

With acute pancreatitis, serum amylase rises within 24 hr of the start of the client's symptoms.

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan?

administer furosemide, administer propranolol, implement a low-sodium diet, measure the client's abdominal girth

A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care?

discontinue suction when assessing or peristalsis, irrigate the NG tube with 0.9% sodium chloride irrigation solution, place sequential compression devices on the bilateral lower extremities

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal tract is digesting and absorbing blood?

As the body digests blood, BUN rises. An elevated BUN is an indication of GI bleeding.

A nurse is providing teaching to a client who has a history of pancreatitis. Which of the following food choices should the nurse instruct the client to avoid?

Clients who have a history of pancreatitis should avoid foods high in fat.

A nurse is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

High-Fowler's. Sitting upright facilitates pooling of peritoneal fluid for easier drainage.

A nurse is caring for four client who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.

A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?

Hypokalemia may be the result of diuretic use, diarrhea, vomiting, and prolonged nasogastric suctioning.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.