Pass Point: Gastrointestinal

A client reports excessive flatulence. Which food, reported by the client as consumed regularly, may be responsible for this?

cauliflower

The nurse is gathering data from a child suspected of ingesting paint chips from an old home. Which system does the nurse closely monitor for serious effects?

central nervous system (CNS)

A client experiences weight loss, abdominal distention, crampy abdominal pain, and intermittent diarrhea after the birth of her second child. Diagnostic tests reveal gluten-induced enteropathy. Which foods would the nurse instruct the client to eliminate from her diet permanently?

cereal grains (except rice and corn)

A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?

A client with bilateral blindness

Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5

A client presents to the outpatient center for a gastroscopy that reveals redness and inflammation of the stomach indicating acute gastritis. Which action should be included in the immediate management?

Treat the underlying cause of disease.

A client with viral hepatitis A is being treated in an acute care facility. To prevent spread of the disease, the nurse uses which precaution?

Wear gloves when caring for the client and wash her hands after touching the client.

A patient underwent open abdominal surgery to remove an intestinal mass 5 days previously and calls the clinic reporting cramping abdominal pain, vomiting, and passing no stool or gas. Which response is most appropriate for the nurse to give to this client?

"Go to the emergency department for evaluation."

A nurse is caring for a client who is receiving enteral feedings through a feeding tube. Which action takes priority in this client's care?

checking placement of the tube

The ingestion of substances containing lead is mostly influenced by which risk factor?

child's age

Oral lactulose is prescribed for the client with a hepatic disorder, and the nurse reinforces instructions to the client regarding this medication. Which statement by the client indicates an understanding of the instructions?

"I need to include more high-fiber foods in my diet."

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for:

diaphoresis, vomiting, and diarrhea.

A nurse is collecting data on a client with a history of constipation. Which data, obtained by the nurse, would indicate a risk factor for constipation?

diet high in cheese, lean meats, and pasta

The nurse is caring for a client who has undergone an open surgical procedure for hiatal hernia repair. Which nursing intervention is a priority?

encouraging incentive spirometer use

A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A?

fecal contamination and oral ingestion

A client is suspected of having gastric cancer. The nurse expects to prepare the client for which diagnostic test that will aid in confirming the diagnosis of gastric cancer?

gastroscopy

A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider?

heart rate 126 bpm

An older adult client with a history of atrial fibrillation takes 5 mg of warfarin daily. Warfarin therapy increases the client's risk for which complications? Select all that apply.

hemorrhage hepatitis hematuria

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When monitoring TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

hyperglycemia

The nurse is caring for a client in the immediate postoperative phase after undergoing gastric surgery. Which is the priority action by the nurse?

monitoring for symptoms of hemorrhage

Which interventions should the nurse perform when caring for a client with acute gastritis? Select all that apply.

monitoring laboratory values assess for changes in abdominal status

A nurse is caring for a client with active upper gastrointestinal (GI) bleed. Which diet is appropriate for this client during the first 24 hours after admission?

nothing by mouth

A client has been admitted to the emergency department with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented in the chart shown, the nurse would expect the client to have which diagnosis?

pancreatitis

The nurse is caring for a client with esophageal varices. What is a priority intervention when caring for this client?

recognizing hemorrhage

Which process best describes the mode of action of medications such as ranitidine, which are used in the treatment of peptic ulcer disease?

reduce acid secretions

A nurse is evaluating the effectiveness of therapy with acetylcysteine in a child with acetaminophen poisoning. Which laboratory values would be most important for the nurse to monitor?

serum alanine aminotransferase (ALT)

The nurse receives a client at the clinic for follow-up after being treated in the hospital for pancreatitis. When gathering data from the client, which finding should immediately be reported to the health care provider?

shortness of breath with minimal exertion

A client diagnosed with glossitis is prescribed a diet high in folic acid. When assisting with the development of a teaching plan for this client, which food products will the nurse reinforce to fulfill the need for increased folic acid?

spinach

The nurse is caring for a client receiving bolus gastrointestinal tube feeding. The nurse checks for residual before instilling the next bolus feeding and aspirates 120 mL. Which are the most appropriate actions by the nurse?

Withhold the feeding and notify the health care provider.

When reviewing the medical record of a client, which factor leads the nurse to suspect that the client is at risk for chronic gastritis?

taking naproxen three times a day for a sports injury

A client needs to have a fecal occult blood test performed on three consecutive bowel movements. To prepare the client for this test, the nurse provides information about the required dietary restrictions. The nurse knows the teaching has been successful when the client makes which statement?

"I should not eat any poultry, red meat, and turnips for 4 days before I begin this test."

The nurse is reinforcing discharge instructions to a client with chronic cholecystitis. Which response by the client indicates the education has been effective?

"I will take my anticholinergic medications as prescribed."

The nurse reinforces home care instructions given to a client with a diagnosis of hiatal hernia. Which statement made by the client indicates an understanding of the instructions?

"I'll sleep with my head elevated about 3 to 4 inches."

A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions?

"I'll take all of my antibiotics."

A recently admitted client suspected of having peritonitis is requesting a glass of water to drink. What is the best response by the nurse?

"It wouldn't be safe to give you anything to drink."

The nurse reinforces discharge education for a client with Crohn's disease. Which long-term symptom management instruction should the nurse reinforce to this client?

"Keep a food diary and eat small, frequent meals."

A client comes to the clinic for a follow-up appointment after diagnostic tests show gastroesophageal reflux disease. What instructions should the nurse reinforce?

"Avoid alcohol and caffeine."

A client with recent onset of epigastric discomfort is scheduled for an upper GI series (barium swallow). When teaching the client how to prepare for the test, which instruction should the nurse provide?

"Avoid eating or drinking anything for 6 to 12 hours before the test."

During a client-teaching session, the nurse includes which instruction to a client receiving kaolin and pectin for treatment of diarrhea?

"Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily."

A nurse reinforces education that has been provided to an older adult about good bowel habits. Which statement indicates that the client understands the information?

"Fifteen minutes of exercise three times a week improves bowel habits."

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The nurse asks which question that demonstrates her understanding of Mallory-Weiss tearing?

"Tell me about your husband's alcohol usage."

After laparoscopic cholecystectomy, a client reports abdominal pain. The nurse prepares morphine 2 mg. If the label on the morphine reads 10 mg/ml, how many milliliters should the nurse have in the syringe after the correct dose is drawn up? Record your answer using one decimal place.

0.2

A client is ordered to receive 1 g of neomycin sulfate orally every hour × 4 doses followed by 1 g orally every 4 hours for the remaining balance of the 24 days. Neomycin sulfate tablets are available in 500 mg per tablet. How many tablets should the nurse administer for each dose? Record your answer using a whole number.

2

A client who has been treated for diverticulitis is being discharged on oral propantheline bromide. The nurse should instruct the client to take the drug at which times?

30 minutes before meals and at bedtime

A nurse is assigned to care for four clients. Which client should a nurse assess first?

A postoperative client who just returned from surgery and is vomiting

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

A client has just been diagnosed with hepatitis A. During assessment, which signs and/or symptoms would the nurse anticipate to find?

Anorexia, nausea, and vomiting.

As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture, 60 ml by mouth after each loose bowel movement, up to eight doses daily. The nurse informs the client that the medication will take effect in how many minutes?

Within 30 minutes

A client with cholelithiasis has a gallstone lodged in the common bile duct is admitted to the medical-surgical unit. During the nurse's assessment of this client, he or she will document which finding?

Yellow sclerae.

While obtaining a client's medication history, the nurse learns that the client takes ranitidine, as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should instruct the client to avoid taking a drug from which class with ranitidine?

Antacids

The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?

Anticholinergic drugs

A nurse is working with a nursing assistant, who is given the task of calculating three clients' intake and output at the end of the shift. When the nurse reviews the nursing assistant's work, she discovers inaccuracies in the nursing assistant's results. What should the nurse do?

Ask the nursing assistant to show her how she determined the results

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse observes the client during feeding and is concerned most with which potential development?

Aspiration

The nurse is admitting a client with abdominal pain, bloody stools, weakness, and dizziness when the client reports feeling the urge to have a bowel movement. What is the priority action by the nurse?

Assist the client onto the bedpan.

A client is being discharged from the acute care facility after experiencing acute pancreatitis. Which instruction should the nurse reinforce to this client during discharge education?

Avoid spicy foods and caffeine.

The physician orders morphine for a client who complains of postoperative abdominal pain. The nurse is monitoring the client and will anticipate administering morphine at what time?

Before the pain becomes severe

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse instructs the nursing student to observe this client's stools for which finding?

Black and tarry

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's dusky-appearing stoma is related to which factor?

Blood supply to the stoma has been interrupted.

A client had a gastroscopy while under local anesthesia. Before resuming the client's oral fluid intake, which action should the nurse take first?

Check for a gag reflex.

A client diagnosed with cirrhosis of the liver caused by alcohol abuse is noncompliant with the prescribed protein-restricted diet. After a friend finds the client semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he's diagnosed with hepatic encephalopathy. The physician prescribes lactulose, 200 gram diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition would the nurse expect to administer lactulose?

Constipation

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

Ineffective breathing pattern

A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client?

Determine what the client already knows about colostomies.

A client with cirrhosis is admitted to the hospital. The nurse observes the client for which sign or symptom that would indicate deterioration of hepatic function?

Difficulty in arousal

After an abdominal cholecystectomy and exploration of the common bile duct, a client returns to the nursing unit with an IV line, an indwelling urinary catheter, a closed wound drainage system, and a T-tube in place. How will the nurse chart the client's output at the end of the shift?

Document and label the measured output from each device separately.

A client with a new colostomy asks the nurse how to avoid detachment from the ostomy bag. What is the best response by the nurse?

Empty the bag when it's about half full.

A male client has acute upper GI bleeding. Which diagnostic test would the nurse first prepare the client for first to evaluate his acute upper GI bleeding?

Endoscopy

Which information should the nurse include when reinforcing instructions regarding routine screening recommendations for colorectal cancer?

Guaiac-based fecal occult blood test (gFOBT) should begin at age 50 years.

The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?

Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma

A nurse approaches a client with an 0800 dose of his scheduled pancreatin. The client states, "I'm not going to take that medicine. It makes me nauseated." What should the nurse do first?

Instruct the client about the benefit of taking the medication.

A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

It has a short duration of action.

A parent brings a child to the emergency department after the child ingested a poisonous hydrocarbon. What is a priority nursing action?

Keep the child calm and relaxed.

When counseling a client in the ways to prevent cholecystitis, which guideline is most important for the nurse to include?

Keep weight proportional to height.

A client is receiving a cleansing enema. During the procedure, the client reports abdominal cramping. What should the nurse do?

Lower the fluid bag so that the instillation slows.

Which nursing intervention is important for the nurse to perform preoperatively for a child with appendicitis?

Maintain complete bed rest.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan?

Metallic taste

The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair?

Monitor for excessive secretions.

A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?

Move him to the next available window-side bed.

A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do?

Notify the client's physician.

A nurse is caring for a child who has been treated in the emergency department after ingesting drain cleaner. Which nursing interventions would be appropriate in this child care? (Select all that apply.)

Observe vital signs for subtle changes. Determine the child's ability to speak. Observe for swelling of the tongue.

The nurse receives a shift report on a client who is 2 days postoperative bowel resection and reports the sudden onset of pain unrelieved by pain medication. The abdomen is rigid and bowel sounds are absent. Which action should the nurse take next?

Obtain a complete set of vital signs.

A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure?

Peristomal skin irritation

The nurse is caring for a client diagnosed with cholecystitis. What intervention can the nurse provide to decrease pressure on the inflamed gallbladder?

Place the client in Fowler's position.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed

When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern?

Promoting defecation

Which nursing intervention is the best way to help reduce the occurrence of poisoning in children?

Provide education to those who care for children.

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer?

Provide meticulous mouth care as needed.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

Relieving abdominal pain

A client is scheduled for a laparoscopic cholecystectomy under general anesthesia. When the nurse asks the client what procedure the client will be having to compare with the informed consent, the client responds, "The doctor is going to take a piece of my liver out." What action should the nurse take at this time?

Request that the health care provider speak with the client before surgery to clarify the surgical procedure.

A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?

Sign the consent only if she sees the client sign it.

A nurse is gathering data on a client receiving an enteral feeding who suddenly states, "I feel very faint and sweaty." What is the nurse's immediate action?

Stop the feeding.

Which outcome indicates effective client teaching to prevent constipation?

The client reports engaging in a regular exercise regimen.

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part.

The nurse is caring for a client with alcohol-related acute pancreatitis. Which intervention is most appropriate to reduce the exacerbation of pain?

abstaining from alcohol

A client who takes famotidine for gastritis asks the home care nurse which medication is best to take for a headache. Which over-the-counter medication should the nurse suggest for this client?

acetaminophen

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

A client is admitted with suspected cirrhosis. Which data collection should the nurse expect to find? Select all that apply.

bleeding from the gums muscle wasting

A client comes to the emergency department reports of acute GI distress. When obtaining the client's history, the nurse inquires about the client's family history and expects to obtain a familial history of which disorders? Select all that apply.

ulcerative colitis peptic ulcer disease

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:

water.

The nurse is reviewing laboratory results for a client with peritonitis. Which results would the nurse expect to observe?

white blood cell (WBC) count above 15,000/μL