Care GI Exam (ch. 48-52, 55)

trauma and severe obesity, risk for:

-impaired gas exchange -skin integrity

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patient's health complaint? A)Stomach emptying takes place more slowly. B)The villi and epithelium of the small intestine become thinner. C)The esophageal sphincter becomes incompetent. D)Saliva production decreases.

A Delayed gastric emptying occurs in older adults and may contribute to nausea. Changes to the small intestine and decreased saliva production would be less likely to contribute to nausea. Loss of esophageal sphincter function is pathologic and is not considered an age-related change.

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps? A)Colonoscopy B)Barium enema C)ERCP D)Upper gastrointestinal fibroscopy

A During colonoscopy, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy.

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample? A)NSAIDs B)Acetaminophen C)OTC vitamin D supplements D)Fiber supplements

A NSAIDs can cause a false-positive fecal occult blood test. Acetaminophen, vitamin D supplements, and fiber supplements do not have this effect.

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any type of palpation. c. Lightly palpate the RUQ first. d. Lightly palpate the RUQ last.

d

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient 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? A)Your appendix doesn't play a major role, so you won't notice any difference after you recovery from surgery. B)The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate. C)Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this. D)Your large intestine will adapt over time to the absence of your appendix.

A The appendix is an appendage of the cecum (not the large intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.

The nurse is preparing to perform a patient's abdominal assessment. What examination sequence should the nurse follow? A)Inspection, auscultation, percussion, and palpation B)Inspection, palpation, auscultation, and percussion C)Inspection, percussion, palpation, and auscultation D)Inspection, palpation, percussion, and auscultation

A When performing a focused assessment of the patient's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds. The traditional sequence for all other focused assessments is inspection, palpation, percussion, and auscultation.

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient? A)Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food. B)As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid. C)The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment. D)The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus.

A The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment.

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel 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? A)Inflammatory bowel disease B)Intestinal polyps C)Diverticulitis D)Colon cancer

A The use of a lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. It can safely be used with patients who have polyps, colon cancer, or diverticulitis.

The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client? A. "It would be very helpful if you could integrate more physical activity into your routine." B. "You're considered to be overweight, so you should be diligent about maintaining a healthy diet." C. "You might want to consider some of the surgical options that have been developed for treating obesity." D. "With your permission, I'd like you to refer to a support group for individuals who live with severe obesity."

A. "It would be very helpful if you could integrate more physical activity into your routine."

A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gaugetube. D. Topical anesthetics will be used to reduce discomfort during insertion

A. Insertion is likely to cause some gagging.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may causehepatic damage. C. Small amounts of blood are likely to be present in the stools and are not causefor concern. D. Antacids may be discontinued when symptoms of heartburn subside.

A. The client will be monitored closely to detect malignant changes.

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by: A. cleaning and drying regularly within the client's skin folds. B. avoiding the use of pillows to position the client. C. making a referral to physical therapy. D. ensuring the client receives a high-calorie, high-protein diet.

A. cleaning and drying regularly within the client's skin folds.

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a. "Let's discuss potential factors that increase your symptoms." b. "If you take the prescribed medications, you will no longer have diarrhea." c. "To decrease distress, do not eat anything before you go out." d. "You must retake control of your life. I will consult a therapist to help."

ANS: A Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can increase symptoms. These factors should be identified so that the client will have more control over his or her condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may assist the client, this is not an appropriate response.

A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion

ANS: A Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Pale and bluish stoma b. Liquid stool c. Ostomy pouch intact d. Blood-smeared output

ANS: A The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may contain some blood.

11. A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

20. A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen b. Temperature of 100.0° F (37.8° C) c. Loose and bloody stool d. Lower abdominal cramps

ANS: A The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohn's disease.

16. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond? a. The stool will always be liquid with this type of colostomy. b. Eating additional fiber will bulk up your stool and decrease diarrhea. c. Your stool will become firmer over the next couple of weeks. d. This is abnormal. I will contact your health care provider.

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time.

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding - Erosion of the bowel wall b. Abscess formation - Localized pockets of infection develop in the ulcerated bowel lining c. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer e. Fistula - Dilation and colonic ileus caused by paralysis of the colon

ANS: A, B, D Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known as a toxic megacolon.

A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Distended abdomen b. Inability to pass flatus c. Bradycardia d. Hyperactive bowel sounds e. Decreased urine output

ANS: A, B, E A client with peritonitis may present with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output secondary to dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.

3. A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.) a. Which food types cause an exacerbation of symptoms? b. Where is your pain and what does it feel like? c. Have you lost a significant amount of weight lately? d. Are your stools soft, watery, and black in color? e. Do you experience nausea associated with defecation?

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the clients pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The clients head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

8. A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the clients upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the clients skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the clients nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction.

1. After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care? a. Low-fiber diet b. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

ANS: B Protecting the client's skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of care for a client who has Crohn's disease includes adequate nutrition focused on high-calorie, high-protein, high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids.

A client has a pyloric obstruction and reports sudden muscle weakness. What action by the nurse takes priority? a. Document the findings in the chart. b. Request an electrocardiogram (ECG). c. Facilitate a serum potassium test. d. Place the client on bedrest.

ANS: B Pyloric stenosis can lead to hypokalemia, which is manifested by muscle weakness. The nurse first obtains an ECG because potassium imbalances can lead to cardiac dysrhythmias. A potassium level is also warranted, as is placing the client on bedrest for safety. Documentation should be thorough, but none of these actions takes priority over the ECG.

A nurse cares for a client with a new ileostomy. The client states, "I don't think my friends will accept me with this ostomy." How should the nurse respond? a. "Your friends will be happy that you are alive." b. "Tell me more about your concerns." c. "A therapist can help you resolve your concerns." d. "With time you will accept your new body."

ANS: B Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the client to discuss concerns. The nurse should not minimize the client's concerns or provide false reassurance.

8. A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client.

After teaching a client who has a new colostomy, the nurse provides feedback based on the client's ability to complete self-care activities. Which statement should the nurse include in this feedback? a. "I realize that you had a tough time today, but it will get easier with practice." b. "You cleaned the stoma well. Now you need to practice putting on the appliance." c. "You seem to understand what I taught you today. What else can I help you with?" d. "You seem uncomfortable. Do you want your daughter to care for your ostomy?"

ANS: B The nurse should provide both approval and room for improvement in feedback after a teaching session. Feedback should be objective and constructive, and not evaluative. Reassuring the client that things will improve does not offer anything concrete for the client to work on, nor does it let him or her know what was done well. The nurse should not make the client convey learning needs because the client may not know what else he or she needs to understand. The client needs to become the expert in self-management of the ostomy, and the nurse should not offer to teach the daughter instead of the client.

The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the clients abdomen is tense and rigid. What action takes priority? a. Administer the prescribed pain medication. b. Notify the health care provider immediately. c. Percuss all four abdominal quadrants. d. Take and document a set of vital signs.

ANS: B This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

2. After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I must change the ostomy appliance daily and as needed. b. I will use warm water and a soft washcloth to clean around the stoma. c. I might start bicycling and swimming again once my incision has healed. d. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown. e. I will check the stoma regularly to make sure that it stays a deep red color. f. I must avoid dairy products to reduce gas and odor in the pouch.

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the clients skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. Exercise (other than some contact sports) is important for clients with an ostomy. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

7. A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

18. A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care? a. You may experience nausea and vomiting for the first few weeks. b. Carbonated beverages can help decrease acid reflux from anastomosis sites. c. Take a stool softener to promote softer stools for ease of defecation. d. You may return to your normal workout schedule, including weight lifting.

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

9. A nurse cares for a client with colon cancer who has a new colostomy. The client states, I think it would be helpful to talk with someone who has had a similar experience. How should the nurse respond? a. I have a good friend with a colostomy who would be willing to talk with you. b. The enterostomal therapist will be able to answer all of your questions. c. I will make a referral to the United Ostomy Associations of America. d. You'll find that most people with colostomies don't want to talk about them.

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse.

19. A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. Eat low-fiber and low-residual foods. b. White rice and bread are easier to digest. c. Add vegetables such as broccoli and cauliflower to your new diet. d. Foods high in animal fat help to protect the intestinal mucosa.

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find? a. Positive Murphy's sign with rebound tenderness to palpitation b. Dull, hypoactive bowel sounds in the lower abdominal quadrants c. High-pitched, rushing bowel sounds in the right lower quadrant d. Reports of abdominal cramping that is worse at night

ANS: C The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn's disease. A positive Murphy's sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohn's disease. Nightly worsening of abdominal cramping is not consistent with Crohn's disease.

nurse cares for a teenage girl with a new ileostomy. The client states, "I cannot go to prom with an ostomy." How should the nurse respond? a. "Sure you can. Purchase a prom dress one size larger to hide the ostomy appliance." b. "The pouch won't be as noticeable if you avoid broccoli and carbonated drinks prior to the prom." c. "Let's talk to the enterostomal therapist about options for ostomy supplies and dress styles." d. "You can remove the pouch from your ostomy appliance when you are at the prom so that it is less noticeable."

ANS: C The ostomy nurse is a valuable resource for clients, providing suggestions for supplies and methods to manage the ostomy. A larger dress size will not necessarily help hide the ostomy appliance. Avoiding broccoli and carbonated drinks does not offer reassurance for the client. Ileostomies have an almost constant liquid effluent, so pouch removal during the prom is not feasible.

6. A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing.

14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the clients bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition.

5. A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

21. A nurse cares for a client who has a family history of colon cancer. The client states, My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond? a. If you eat a low-fat and low-fiber diet, your chances decrease significantly. b. You are safe. This is an autosomal dominant disorder that skips generations. c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. d. You should have a colonoscopy more frequently to identify abnormal polyps early.

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer.

A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective Tissue Perfusion Related to Bowel Ischemia B. Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption C. Anxiety Related to Bowel Obstruction and Subsequent Hospitalization D. Impaired Skin Integrity Related to Bowel Obstruction

Ans: A Feedback: When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.

A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal? A. Patient will accurately identify foods that trigger symptoms. B. Patient will demonstrate appropriate care of his ileostomy. C. Patient will demonstrate appropriate use of standard infection control precautions. D. Patient will adhere to recommended guidelines for mobility and activity.

Ans: A Feedback: A major focus of nursing care for the patient with IBS is to identify factors that exacerbate symptoms. Surgery is not used to treat this health problem and infection control is not a concern that is specific to this diagnosis. Establishing causation likely is more important to the patient than managing physical activity.

A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

Ans: A Feedback: Decompression of the bowel through a nasogastric tube is necessary for all patients with small bowel obstruction. Peripheral IV access is normally sufficient. Enemas, suppositories, and laxatives are not indicated if an obstruction is present.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A. The patient will require an upper endoscopy every 6 months to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside.

Ans: A Feedback: In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstruction C. History of diverticulitis D. Longstanding psychosocial stress

Ans: A Feedback: Risk factors include high alcohol intake; cigarette smoking; and high-fact, high-protein, low-fiber diet. Diverticulitis, obstruction, and stress are not noted as risk factors for colorectal cancer.

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A. Watery with blood and mucus B. Hard and black or tarry C. Dry and streaked with blood D. Loose with visible fatty streaks

Ans: A Feedback: The predominant symptoms of ulcerative colitis are diarrhea and abdominal pain. Stools may be bloody and contain mucus. Stools are not hard, dry, tarry, black or fatty in patients who have ulcerative colitis.

A patient was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

Ans: A Feedback: A severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis (narrowing or tightening) or obstruction. Chronic referred pain to the lower abdomen is a symptom of peptic ulcer disease, but would not be an expected finding for a patient who has ingested a corrosive substance. Bacterial proliferation and hyperacidity would not occur.

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A. "Does your pain resolve when you have something to eat?" B. "Do over-the-counter pain medications help your pain?" C. "Does your pain get worse if you get up and do some exercise?" D. "Do you find that your pain is worse when you need to have a bowel movement?"

Ans: A Feedback: Pain relief after eating is associated with duodenal ulcers. The pain of peptic ulcers is generally unrelated to activity or bowel function and may or may not respond to analgesics.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A. Keep the head of the bed lowered. B. Drink a cup of hot tea before bedtime. C. Avoid carbonated drinks. D. Eat a low-protein diet.

Ans: C Feedback: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.

A patient with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the patient's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?" B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?" D. "Do any of your family members have training in first aid?"

Ans: A Feedback: Patients with malabsorption of vitamin B12 need information about lifelong vitamin B12 injections; the nurse may instruct a family member or caregiver how to administer the injections or make arrangements for the patient to receive the injections from a health care provider. Questions addressing sun exposure, blood type and first aid are not directly relevant.

Diagnostic imaging and physical assessment have revealed that a patient with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

Ans: A Feedback: Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A. Examine one's own attitudes towards obesity in general and the patient in particular. B. Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C. Describe one's own struggles with weight gain and weight loss to the patient. D. Elicit the patient's short-term and long-term goals for weight loss.

Ans: A Feedback: Studies suggest that health care providers, including nurses, harbor negative attitudes towards obese patients. Nurses have a responsibility to examine these attitudes and change them accordingly. This is foundational to all other areas of assessing this patient.

A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is now stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

Ans: A Feedback: Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Patients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.

The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

Ans: B Feedback: The hallmarks of malabsorption syndrome from any cause are diarrhea or frequent, loose, bulky, foulsmelling stools that have increased fat content and are often grayish (steatorrhea). Constipation and bloody bowel movements are not suggestive of malabsorption syndromes. Fever and a tender, rigid abdomen are associated with peritonitis.

A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperature B. Frequent abdominal auscultation C. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

Ans: B Feedback: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse.

A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the patient to conduct online research into colostomies. B. Engage the patient in the care of the ostomy to the extent that the patient is willing. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

Ans: B Feedback: For some patients, becoming involved in the care of the ostomy helps to normalize it and enhance familiarity. Emphasizing the benefits of the intervention is unlikely to improve the patients body image, since the benefits are likely already known. Online research is not likely to enhance the patients body image and some ostomies are permanent.

A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting? A. Apply antibiotic ointment as ordered after cleaning the stoma. B. Apply a skin barrier to the peristomal skin prior to applying the pouch. C. Dispose of the clamp with each bag change. D. Cleanse the area surrounding the stoma with alcohol or chlorhexidine

Ans: B Feedback: Guidelines for changing an ileostomy appliance are as follows. Skin should be washed with soap and water, and dried. A skin barrier should be applied to the peristomal skin prior to applying the pouch. Clamps are supplied one per box and should be reused with each bag change. Topical antibiotics are not utilized, but an antifungal spray or powder may be used.

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. A. Malignant hyperthermia B. Atelectasis C. Pneumonia D. Metabolic imbalances E. Chronic gastritis

Ans: B, C, D Feedback: After surgery, the nurse assesses the patient for complications secondary to the surgical intervention, such as pneumonia, atelectasis, or metabolic imbalances resulting from the GI disruption. Malignant hyperthermia is an intraoperative complication. Chronic gastritis is not a surgical complication.

A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the physician. C. Encourage the patient to mobilize in order to enhance motility. D. Contact the physician and obtain a swab of the stoma for culture.

Ans: B Feedback: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem.

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? A. Spinach B. Tofu C. Multigrain bagel D. Blueberries

Ans: B Feedback: Nutritional management of inflammatory bowel disease requires ingestion of a diet that is bland, lowresidue, high-protein, and high-vitamin. Tofu meets each of the criteria. Spinach, multigrain bagels, and blueberries are not low-residue.

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD? A. Pyloric sphincter B. Lower esophageal sphincter C. Hypopharyngeal sphincter D. Upper esophageal sphincter

Ans: B Feedback: The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the patient to take stool softener daily. B. Assess the patients food and fluid intake. C. Assess the patients surgical history. D. Encourage the patient to take fiber supplements.

Ans: B Feedback: The nurse should follow the nursing process and perform an assessment prior to interventions. The patients food and fluid intake is more likely to affect bowel function than surgery.

Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? A. Eating several small meals daily rather than 3 larger meals B. Keeping the head of the bed slightly elevated C. Drinking carbonated mineral water rather than soft drinks D. Avoiding food or fluid intake after 6:00 p.m.

Ans: B Feedback: The patient with GERD is encouraged to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks. Frequent meals are not specifically encouraged and the patient should avoid food and fluid within 2 hours of bedtime. All carbonated beverages should be avoided.

A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake B. Risk for Infection Related to Possible Rupture of Appendix C. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake D. Chronic Pain Related to Appendicitis

Ans: B Feedback: The patient with a diagnosis of appendicitis has an acute risk of infection related to the possibility of rupture. This immediate physiologic risk is a priority over nutrition and constipation, though each of these concerns should be addressed by the nurse. The pain associated with appendicitis is acute, not chronic.

A nurse is caring for a patient who has just been diagnosed with a peptic ulcer. When teaching the patient about his new diagnosis, how should the nurse best describe a peptic ulcer? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

Ans: B Feedback: A peptic ulcer is erosion of the lining of the stomach or intestine. Peptic ulcers are often accompanied by bleeding and inflammation, but these are not the definitive characteristics.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A.The patient has abdominal bloating that developed rapidly. B. The patient has a rigid, "boardlike" abdomen that is tender. C. The patient is experiencing intense lower right quadrant pain. D. The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

Ans: B Feedback: An extremely tender and rigid (boardlike) abdomen is suggestive of a perforated ulcer. None of the other listed signs and symptoms is suggestive of a perforated ulcer.

A patient has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as ordered

Ans: B Feedback: In treating the patient with gastric outlet obstruction, the first consideration is to insert an NG tube to decompress the stomach. This is a priority over fluid or medication administration.

A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment? A. Bowel incontinence B. Flatus with oily discharge C. Abdominal pain D. Heat intolerance

Ans: B Feedback: Side effects of orlistat include increased frequency of bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. This drug does not cause bowel incontinence, abdominal pain, or heat intolerance.

A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity.

Ans: C Feedback: A healthy, viable stoma should be shiny and pink to bright red. This finding does not indicate that the stoma is blocked or that skin integrity is compromised.

A patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patients health problem? A. Adherence to a high-fiber diet will help the polyps resolve. B. The patient should be assured that these are a normal, age-related physiologic change. C. The patients polyps constitute a risk factor for cancer. D. The presence of polyps is associated with an increased risk of bowel obstruction.

Ans: C Feedback: Although most polyps do not develop into invasive neoplasms, they must be identified and followed closely. They are very common, but are not classified as a normal, age-related physiologic change. Diet will not help them resolve and they do not typically lead to obstructions.

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

Ans: C Feedback: Bloody stool is far more common in cases of UC than in Crohns. Rectal involvement is nearly 100% in cases of UC (versus 20% in Crohns) and patients with UC typically experience severe diarrhea. UC is also characterized by a pattern of remissions and exacerbations, while Crohns often has a more prolonged and variable course.

A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge? A. The familys ability to take care of the patients special diet needs B. The familys ability to monitor the patients changing health status C. The familys ability to provide emotional support D. The familys ability to manage the patients medication regimen

Ans: C Feedback: Emotional support from the family is key to the patients coping after discharge. A 21-year-old would be expected to self-manage the prescribed medication regimen and the family would not be primarily responsible for monitoring the patients health status. It is highly beneficial if the family is willing and able to accommodate the patients dietary needs, but emotional support is paramount and cannot be solely provided by the patient alone.

A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

Ans: C Feedback: Goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications. Ongoing use of pharmacologic aids should not be promoted, due to the risk of dependence. Increased mobility helps to maintain a regular pattern of elimination. The urge to defecate should be heeded.

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat diet B. Annual screening endoscopy for patients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy foods

Ans: C Feedback: There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history.

A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions? A. Aim to eventually empty the pouch every 90 minutes. B. Avoid emptying the pouch until it is visibly full. C. Insert the catheter approximately 5 cm into the pouch. D. Aspirate the contents of the pouch using a 60 mL piston syringe.

Ans: C Feedback: To empty a Kock pouch, the catheter is gently inserted approximately 5 cm to the point of the valve or nipple. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. It is not appropriate to wait until the pouch is full, and this would not be visible. The contents of the pouch are not aspirated.

A nurse is preparing to discharge a patient after recovery from gastric surgery. What is an appropriate discharge outcome for this patient? A. The patient's bowel movements maintain a loose consistency. B. The patient is able to tolerate three large meals a day. C. The patient maintains or gains weight. D. The patient consumes a diet high in calcium.

Ans: C Feedback: Expected outcomes for the patient following gastric surgery include ensuring that the patient is maintaining or gaining weight (patient should be weighed daily), experiencing no excessive diarrhea, and tolerating six small meals a day. Patients may require vitamin B12 supplementation by the intramuscular route and do not require a diet excessively rich in calcium.

A nurse is completing a health history on a patient whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the patient's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.

Ans: C Feedback: Nicotine reduces secretion of pancreatic bicarbonate, which inhibits neutralization of gastric acid and can underlie gastritis. Protein drinks do not result in gastric inflammation. Antacid use is a response to experiencing symptoms of gastritis, not the etiology of gastritis. Alcohol ingestion can lead to gastritis; however, this generally occurs in patients with a history of consumption of alcohol on a daily basis.

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity? A. "Weight loss drugs have many side effects, and most doctors think they'll all be off the market in a few years." B. "There used to be a lot of hope that medications would help people lose weight, but it's been shown to be mostly a placebo effect." C. "Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone." D. "Medications are rapidly become the preferred method of weight loss in people for whom diet and exercise have not worked."

Ans: C Feedback: Though antiobesity drugs help some patients lose weight, their use rarely results in loss of more than 10% of total body weight. Patients are consequently unlikely to attain their desired weight through medication alone. They are not predicted to disappear from the market and results are not attributed to a placebo effect.

A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

Ans: D Feedback: All of the listed focuses of care are important for the patient with a small bowel obstruction. However, the patients risk of fluid and electrolyte imbalances is an immediate threat to safety, and is a priority in nursing assessment and interventions.

A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate? A. Reassure the patient that the procedure is relatively low risk and that patients are usually successful in adjusting to an ostomy. B. Provide the patient with educational materials that match the patients learning style. C. Encourage the patient to write down these concerns and questions to bring forward to the surgeon. D. Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomycontinence (WOC) nurse.

Ans: D Feedback: A wound-ostomy-continence (WOC) nurse is a registered nurse who has received advanced education in an accredited program to care for patients with stomas. The enterostomal nurse therapist can assist with the selection of an appropriate stoma site, teach about stoma care, and provide emotional support. The surgeon is less likely to address the patients psychosocial and learning needs. Reassurance does not address the patients questions, and education may or may not alleviate anxiety.

A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. Drinking beverages after your meal, rather than with your meal, may bring some relief. B. It's best to avoid dry foods, such as rice and chicken, because theyre harder to swallow. C. Many patients obtain relief by taking over-the-counter antacids 30 minutes before eating. D. Instead of eating three meals a day, try eating smaller amounts more often.

Ans: D Feedback: Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.

A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. What pharmacologic intervention should the nurse recommend to the patient for ongoing use? A. Mineral oil enemas B. Bisacodyl (Dulcolax) C. Senna (Senokot) D. Psyllium hydrophilic mucilloid (Metamucil)

Ans: D Feedback: Psyllium hydrophilic mucilloid (Metamucil) is a bulk-forming laxative that is safe for ongoing use. None of the other listed laxatives should be used on an ongoing basis because of the risk of dependence.

A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer? A. Development of new hemorrhoids B. Abdominal bloating and flank pain C. Unexplained weight gain D. Change in bowel habits

Ans: D Feedback: The most common presenting symptom associated with colorectal cancer is a change in bowel habits. The passage of blood is the second most common symptom. Symptoms may also include unexplained anemia, anorexia, weight loss, and fatigue. Hemorrhoids and bloating are atypical.

A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient? A. Administering bowel stimulants as ordered B. Administering bulk-forming laxatives as ordered C. Performing deep palpation as ordered to promote peristalsis D. Preparing the patient for surgical bowel resection

Ans: D Feedback: The usual treatment for a large bowel obstruction is surgical resection to remove the obstructing lesion. Administration of laxatives or bowel stimulants are contraindicated if the bowel is obstructed. Palpation would be painful and has no therapeutic benefit.

A nurse is caring for a patient hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

Ans: D Feedback: Measures to help relieve pain include instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and instructing the patient about the correct use of medications to relieve chronic gastritis. An alkaline gastric environment is neither possible nor desirable. There is no plausible need for self-suctioning. Positioning does not have a significant effect on the presence or absence of gastric healing.

A nurse is caring for a patient who has a diagnosis of GI bleed. During shift assessment, the nurse finds the patient to be tachycardic and hypotensive, and the patient has an episode of hematemesis while the nurse is in the room. In addition to monitoring the patient's vital signs and level of consciousness, what would be a priority nursing action for this patient? A. Place the patient in a prone position. B. Provide the patient with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the physician.

Ans: D Feedback: The nurse must always be alert for any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. If these occur, the physician is notified and the patient's vital signs are monitored as the patient's condition warrants. Putting the patient in a prone position could lead to aspiration. Giving ice water is contraindicated as it would stimulate more vomiting.

A female patient has presented to the emergency department with right upper quadrant pain; the physician has ordered abdominal ultrasound to rule out cholecystitis (gallbladder infection). The patient expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A)Abdominal ultrasound is very safe, but it can't be performed if you're pregnant. B)Abdominal ultrasound poses no known safety risks of any kind. C)Current guidelines state that a person can have up to 3 ultrasounds per year. D)Current guidelines state that a person can have up to 6 ultrasounds per year.

B An ultrasound produces no ill effects and there are not specific limits on its use, even during pregnancy.

A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A)Sigmoid colon B)Upper GI tract C)Large intestine D)Anus or rectum

B Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds? A)Normal B)Hypoactive C)Hyperactive D)Paralytic ileus

B Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.

A patient's sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patient's discharge education? A)The patient should drink at least 2 liters of fluid in the next 12 hours. B)The patient can resume a normal routine immediately. C)The patient should expect fecal urgency for several hours. D)The patient can expect some scant rectal bleeding.

B Following sigmoidoscopy, patients can resume their regular activities and diet. There is no need to push fluids and neither fecal urgency nor rectal bleeding is expected.

Results of a patient's preliminary assessment prompted an examination of the patient's carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurse's most appropriate response to this finding? A)Perform a focused abdominal assessment. B)Prepare to meet the patient's psychosocial needs. C)Liaise with the nurse practitioner to perform an anorectal examination. D)Encourage the patient to adhere to recommended screening protocols.

B)Prepare to meet the patient's psychosocial needs.

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea

B. Aspiration

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A)Remain NPO for 6 hours postprocedure. B)Administer a Fleet enema to cleanse the bowel of the barium. C)Increase fluid intake to evacuate the barium. D)Avoid dairy products for 24 hours postprocedure.

C Adequate fluid intake is necessary to rid the GI tract of barium. The patient must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products.

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test? A)In a knee-chest position (lithotomy position) B)Lying prone with legs drawn toward the chest C)Lying on the left side with legs drawn toward the chest D)In a prone position with two pillows elevating the buttocks

C For best visualization, colonoscopy is performed while the patient is lying on the left side with the legs drawn up toward the chest. A kneechest position, lying on the stomach with legs drawn to the chest, and a prone position with two pillows elevating the legs do not allow for the best visualization.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test? A)Stool will be yellow for the first 24 hours postprocedure. B)The barium may cause diarrhea for the next 24 hours C)Fluids must be increased to facilitate the evacuation of the stool D)Slight anal bleeding may be noted as the barium is passed.

C Postprocedural patient education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements, because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation? A)You'll need to fast for at least 18 hours prior to your test. B)Starting today, take over-the-counter stool softeners twice daily. C)You'll need to have enemas the day before the test. D)For 24 hours before the test, insert a glycerin suppository every 4 hours.

C Preparation of the patient includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract? A)The breakdown of food particles into cell form for digestion B)The maintenance of fluid and acid-base balance C)The absorption into the bloodstream of nutrient molecules produced by digestion D)The control of absorption and elimination of electrolytes

C Primary functions of the GI tract include the breakdown of food particles into molecular form for digestion; the absorption into the bloodstream of small nutrient molecules produced by digestion; and the elimination of undigested unabsorbed food stuffs and other waste products. Nutrients must be broken down into molecular form, not cell form. Fluid, electrolyte, and acid-base balance are primarily under the control of the kidneys.

The nurse is caring for a patient with a duodenal ulcer and is relating the patient's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A)Secretion of hydrochloric acid (HCl) B)Reabsorption of water C)Secretion of mucus D)Absorption of nutrients E)Movement of nutrients into the bloodstream

C, D, E The small intestine folds back and forth on itself, providing approximately 7000 cm2 (70 m2) of surface area for secretion and absorption, the process by which nutrients enter the bloodstream through the intestinal walls. Water reabsorption primarily takes place in the large bowel. HCl is secreted by the stomach.

An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician? A)Large, wide stools B)Milky white stools C)Three stools during an 8-hour period of time D)Streaks of blood present in the stool

D Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? a. Listen to the client's bowel sounds. b. Call the Rapid Response Team. c. Take the client's vital signs. d. Contact the primary health care provider

c. Take the client's vital signs. The client may be experiencing either bleeding or anastomosis leak(s). Clients having these complications have severe abdominal, back, or shoulder pain, tachycardia, and hypotension

A patient 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 patient, what advantage should the nurse describe? A)The test allows visualization of the entire peritoneal cavity. B)The test allows for painless biopsy collection. C)The test does not require fasting. D)The test is noninvasive.

D Capsule endoscopy allows the noninvasive visualization of the mucosa throughout the entire small intestine. Bowel preparation is necessary and biopsies cannot be collected. This procedure allows visualization of the entire GI tract, but not the peritoneal cavity.

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A)Increased gastric motility B)Decreased gastric pH C)Increased gag reflex D)Decreased mucus secretion

D Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient? A)Take all your medications as usual. B)Take all your medications except the antihypertensive medications. C)Don't eat highly acidic foods 72 hours before you start the test. D)Avoid vitamin C for 72 hours before you start the test.

D Red meats, aspirin, nonsteroidal anti-inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study, because they may cause a false-positive result. Also, ingestion of vitamin C from supplements or foods can cause a false-negative result. Acidic foods do not need to be avoided.

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I'll avoid ibuprofen for several days before the test." d. "I'll buy a case of clear Gatorade before the prep."

a

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine

a

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.) a. Asthma b. Laryngitis c. Dental caries d. Cardiac disease e. Cancer

a b c d e

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.) a. Dyspepsia b. Regurgitation c. Belching d. Coughing e. Chest discomfort f. Dysphagia

a b c d e f

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified

a b c e

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.) a. Obtain vital signs every 15 to 30 minutes until alert. b. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client's serum and urine glucose levels. e. Confirm the client has a ride home and plans to rest.

a b e

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Endoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 5 years

a c e

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

a. Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? a. The client has a healthy weight. b. The client is underweight. c. The client is obese. d. The client is overweight.

c. The client is obese. A BMI of over 30 indicates that the client is obese

When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. d. Provide salty or highly spicy foods that the client can taste. e. Serve high-calorie, high-protein snacks one to two times a day

a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. e. Serve high-calorie, high-protein snacks one to two times a day Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses or contacts, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty or spicy snacks are not recommended because all adults should limit sodium in their diets and spicy foods may not be tolerated

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin

a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin

The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

a. Ask the client if the weight loss was intentional. This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client that lifestyle changes are always hard

a. Assess the client's coping and support systems. The nurse would assess this patient's coping styles and support systems to best provide holistic care. The other options do not address the patient's distress.

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? a. Check the skin around the tube insertion site. b. Weigh the client every shift with the same scale. c. Draw blood to assess albumin every shift. d. Irrigate the tube at least once a day

a. Check the skin around the tube insertion site. The most important assessment would be to observe the skin around the tube for irritation, redness, and skin breakdown. The skin should be cleaned frequently to keep it free of drainage and moisture which can lead to excoriation or other type of skin breakdown. For a client who is undernourished, he or she is usually weighed every day and prealbumin is a more sensitive indicator of over nutritional health. The G-tube is not routinely irrigated

The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

a. Cultural food preferences c. Increased need for nutrition d. Need for NPO status e. Staff shortages Many factors increase the hospitalized client's risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill patients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume that the snacks are leading to undernutrition

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis? a. Esophagogastroduodenoscopy (EGD) b. Abdominal arteriogram c. Nuclear medicine scan d. Magnetic resonance imaging (MRI)

a. Esophagogastroduodenoscopy (EGD)

The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care? a. Maintain airway, breathing, and circulation. b. Monitor vital signs, including orthostatic blood pressures. c. Draw blood for hemoglobin and hematocrit immediately. d. Insert a nasogastric (NG) tube and connect to intermittent suction.

a. Maintain airway, breathing, and circulation.

The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss? a. Walking for 40 minutes 6 or 7 days/week b. Lifting weights with friends 3 times/week c. Playing soccer for an hour on the weekend d. Running for 10 to 15 minutes 3 times/week

a. Walking for 40 minutes 6 or 7 days/week

A RN cares for a pt who is getting TPN solution. THe current bag of solution was hung 24 hour ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? a. remove the current bag and hang a new bag b. infuse the remaining solution at the current rate and then hang a new bag c. increase the infusion rate

a. remove the current bag and hang a new bag

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is appropriate? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.

b

The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) a. "You will need to be on a liquid diet for the first week after the procedure." b. "Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure." c. "Contact the primary health care provider after the procedure if you have increased pain." d. "You will need a nasogastric tube for a few days after the procedure." e. "You will have a small incision in your stomach area that will have a wound closure.

b c

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? a. Client with an albumin of 3.5 g/dL b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) c. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) d. Client with a prealbumin of 28 mg/dL

b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) A cholesterol level below 160 mg/dL (4 mmol/L) is a possible indicator of undernutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding.

The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) a. Decreased heart rate b. Decreased blood pressure c. Bounding radial pulse d. Dizziness e. Hematemesis f. Decreased urinary output

b. Decreased blood pressure d. Dizziness e. Hematemesis f. Decreased urinary output

A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. e. Try to flush the tube with 30 mL of water and gentle pressure. If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide? a. Lavaging the tube with ice water b. Performing frequent oral care c. Re-positioning the tube every 4 hours d. Taking and recording vital signs

b. Performing frequent oral care

report to the physician after a colonoscopy

blood on toilet paper

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come to the clinic this afternoon.

c

A client has an open traditional hiatal hernia repair this morning. What is the nurse's priority for client care at this time? a. Managing surgical pain b. Ambulating the client early c. Preventing respiratory complications d. Managing the nasogastric tube

c

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client? a. Culture and sensitivity b. Parasites and ova c. Occult blood test d. Total fat content

c

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? a. Intermittent diarrhea b. Cholecystitis c. Aspiration pneumonia d. Peptic ulcer disease

c. Aspiration pneumonia Aspiration pneumonia is one of the most common complications in older adults who have enteral nutrition via a nasoduodenal tube because their gag reflex is often decreased. Intermittent diarrhea may also occur, but that is not potentially life threatening if the client does not become dehydrated

A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? a. Assess the patient's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump

c. Ensure an adequate airway. All actions are appropriate care measures for this patient; however, airway is always the priority. Bariatric patients tend to have short, thick necks that complicate airway management

A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the patient's mouth while providing premeal oral care. c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed. The AP should make sure that food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The AP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse

A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the patient's gastric residual. c. Hold the feeding until the vomiting subsides. d. Reduce the rate of the tube feeding by half.

c. Hold the feeding until the vomiting subsides. The nurse would stop the feeding until the vomiting subsides and consult with the registered dietitian nutritionist or primary health care provider about the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse would not continue to feed the patient while he or she is vomiting.

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? a. Hematemesis b. Pain when eating c. Melena d. Weight loss

c. Melena

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? a. Large bowel obstruction b. Dyspepsia c. Upper gastrointestinal (GI) bleeding d. Gastric cancer

c. Upper gastrointestinal (GI) bleeding

patient prescribed TPN, what should the nurse do

check patient's glucose levels

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? a. "I need to cut down on drinking martinis every might." b. "I should decrease my intake of caffeinated drinks, especially coffee." c. "I will only take ibuprofen once in a while when I really need it." d. "I can continue smoking cigarettes which is better than chewing tobacco."

d. "I can continue smoking cigarettes which is better than chewing tobacco."

A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? a. Auscultate lung sounds after each feeding. b. Weigh the client daily on the same scale. c. Check tube placement every 8 hours. d. Check tube placement before each feeding.

d. Check tube placement before each feeding. For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this may indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met, but it is not the priority

The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? a. Assess for carbon dioxide using capnometry. b. Perform pH testing of gastric fluid. c. Auscultate over the epigastric area. d. Request an x-ray before starting the feeding.

d. Request an x-ray before starting the feeding. The most reliable assessment to determine correct feeding tube placement in to have an x-ray to visualize where the tip of the tube is located

A RN teaches a pt about the fecal occult blood test. The pt must mail 3 specimens. Which statement indicates the pt understands the teaching? a. "I will continue taking my warfarin while completing the specimen samples" b. "I'm glad my diet isn't restricted during this time" c. This test will determine if I have parasites in my poop d. This is an easy way to screen for colon cancer

d. This is an easy way to screen for colon cancer