prepu chapter 44

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

Normal

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."

A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?

"Abdominal ultrasound poses no known safety risks of any kind."

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss?

"Do you experience any claustrophobia?"

A client reports having red stools lately. What will the nurse ask during assessment questioning?

"Have you been eating beets?"

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client?

"Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food."

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present."

A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation?

"You'll need to have enemas the day before the test."

In client education with a client who has a lower GI study scheduled, the nurse describes the organs involved and their characteristics. Approximately how long are the jejunum and the ileum if their lengths are combined?

23 feet

Which of the following is the primary function of the small intestine?

Absorption

Which of the following digestive enzymes aids in the digesting of starch?

Amylase

The nurse is performing a focused abdominal assessment of a client with a history of bowel obstruction. The nurse has positioned the client appropriately and inspected the client's abdomen carefully. What action should the nurse perform next?

Auscultate the client's abdomen

A nurse is caring for a client with biliary colic. Where would the nurse most likely expect this client to experience referred pain?

Below the right nipple

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring?

Bowel perforation

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?

Colonoscopy

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this client?

Do not give any food and fluids until the gag reflex returns.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

Encourage plenty of fluids.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

Fluids must be increased to facilitate the evacuation of the stool.

The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure?

Follow the dietary and fluid restrictions and bowel preparation procedures.

A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding?

GI diseases often produce skin changes.

A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause?

Hemorrhoids

A clinic client has described recent dark-colored stools and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT?

Hemorrhoids

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive

A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds?

Hypoactive

Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?

Red

A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery?

Increase fluid intake to evacuate the barium.

A nurse is caring for a client who is scheduled for a colonoscopy and whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?

Inflammatory bowel disease

The nurse is caring for a client who has a diagnosis of AIDS. Inspection of the client's mouth reveals the new presence of white lesions on the client's oral mucosa. What is the nurse's most appropriate response?

Inform the primary provider of this finding.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test?

Lying on the left side with legs drawn toward the chest

A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow?

Medulla oblongata

What part of the GI tract begins the digestion of food?

Mouth

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

Pentagastrin

An advanced practice nurse is assessing the size and density of a client's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?

Percussion

A client is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?

Persistently low hemoglobin and hematocrit

The nurse conducts education related to test preparation for a client scheduled to undergo an abdominal ultrasonography. The nurse should give the client which instruction?

Restrict eating of solid food for 8 to 12 hours before the test.

The nurse is performing assessment of the client's left upper quadrant. Mark the area in which the nurse is examining the client.

Right Upper Quadrant

A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider?

Streaks of blood present in the stool

A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client?

Take no NSAIDs within 48 hours of the test

The nurse is collecting a stool specimen from a patient. What characteristic of the stool indicates to the nurse that the patient may have an upper GI bleed?

Tarry and black

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which nursing intervention is advised for this patient?

The client should not be given any food and fluids until the gag reflex returns.

A client will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study, as prescribed. What would indicate that these medications have had the desired therapeutic effect?

The client's BUN and creatinine levels are within reference range following the CT.

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?

The pancreas secretes digestive enzymes.

A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe?

The test is noninvasive.

The nurse determines which is a true statement regarding older clients, considering the age-related effects on their GI system?

They tend usually to have less control of the rectal sphincter.

The nurse determines which is a true statement regarding older clients, considering the age-related effects on the gastrointestinal (GI) system?

They usually have less control of the rectal sphincter.

A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

Upper GI tract

A client was diagnosed with pernicious anemia. Which vitamin cannot be absorbed without an intrinsic factor?

Vitamin B12

A client who has been in a motor-vehicle collision is comatose and has developed ascites as a result of the accident. The nurse explains the condition to the client's family, and indicates that the primary function of the small intestine is to:

absorb nutrients

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure?

clear liquids day before

A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. The nurse determines which nursing intervention is advised for this client?

do not give any food and fluids until the gag reflex returns

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

duodenum

The nurse assesses bowel sounds and hears one to two bowel sounds in 2 minutes. How should the nurse document the bowel sounds?

hypoactive

The nurse determines one or two bowel sounds in 2 minutes should be documented as

hypoactive.

When assessing an elderly client's gastrointestinal system, it is important for the nurse to remember that older clients tend to have:

less control of the rectal sphincter.

Which procedure is performed to examine and visualize the lumen of the small bowel?

small bowel enteroscopy

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response?

small intestine

The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?

upper GI enteroclysis

the client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?

upper GI enteroclysis

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test."

What composes fecal matter?

All options are correct

A client comes into the emergency department with reports of abdominal pain. What should the nurse ask first?

Characteristics and duration of pain

A nurse is performing an abdominal assessment of an older adult client. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

Decreased mucus secretion

The nurse is investigating a client's report of pain in the duodenal area. Where should the nurse perform the assessment?

Epigastric area and consider possible radiation of pain to the right subscapular region

A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. When examining the client's abdomen, which sequence should the nurse use?

Inspection, auscultation, percussion, and palpation

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow?

Inspection, auscultation, percussion, and palpation

A nurse is assisting with preoperative care for a client who requires an appendectomy. The nurse is aware that the surgery will involve which abdominal quadrant? Mark the correct area.

LLQ

The nurse recognizes which change of the GI system is an age-related change?

weakened gag reflex

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

recent foods ingested.

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer?

red plaque on undersurface of tongue