Chapter 38 - GI Assessment
A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with cold water
ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.
A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.
ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
The nurse will plan to monitor a patient with an obstructed common bile duct for a. melena. b. steatorrhea. c. decreased serum cholesterol levels. d. increased serum indirect bilirubin levels.
ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.
A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meal.
ANS: B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.
Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds
ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.
Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"
ANS: C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.
A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.
ANS: D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.
When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.
ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.
45. The RN and nursing assistant (NA) are caring for a patient with a paralytic ileus. Which of these nursing activities is appropriate for the nurse to delegate to the NA? a. Irrigation of the NG tube with saline b. Retaping the NG tube c. Applying petroleum jelly to the lips d. Auscultation for bowel sounds
C Rationale: NA education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN. Cognitive Level: Comprehension Text Reference: p. 1062 Nursing Process: Implementation NCLEX: Physiological Integrity
41. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. The nurse explains to the patient that a. this type of colostomy is usually temporary. b. soft, formed stool can be expected as drainage. c. the drainage is liquid at this site but less odorous than at higher sites. d. colostomy irrigations can help regulate the drainage from the proximal stoma.
A Rationale: A loop or double-barrel stoma is usually temporary. Cognitive Level: Application Text Reference: p. 1069 Nursing Process: Implementation NCLEX: Physiological Integrity
37. When implementing the initial plan of care for a patient admitted with acute diverticulitis, the nurse will a. administer IV fluids. b. order a diet high in fiber and fluids. c. give stool softeners. d. prepare the patient for colonoscopy.
A Rationale: A patient with acute diverticulitis will be NPO with parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have colonoscopy because of the risk for perforation and peritonitis. Cognitive Level: Application Text Reference: p. 1077 Nursing Process: Implementation NCLEX: Physiological Integrity
8. Two days following an exploratory laparotomy with a resection of a short segment of small bowel, the patient complains of gas pains and abdominal distention. Which nursing action is most appropriate to take at this time? a. Assisting the patient to ambulate b. Administering the ordered IV morphine sulfate c. Giving a return-flow enema d. Inserting the ordered promethazine (Phenergan) suppository
A Rationale: Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the patient's symptoms, but ambulation is less invasive and should be tried first. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention. Cognitive Level: Application Text Reference: p. 1046 Nursing Process: Implementation NCLEX: Physiological Integrity
15. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. The nurse will plan to a. place the patient on NPO status. b. administer Cobalamin (vitamin B12) injections. c. start bowel preparation for colonoscopy. d. administer IV metoclopramide (Reglan).
A Rationale: An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO. Cobalamin (vitamin B12) is absorbed in the ileum, which is not affected by ulcerative colitis. It is not appropriate to administer laxatives needed for colonoscopy to a patient with diarrhea. Metoclopramide increases peristalsis and will worsen symptoms. Cognitive Level: Application Text Reference: p. 1058 Nursing Process: Planning NCLEX: Physiological Integrity
40. In providing discharge teaching for a patient who has undergone a hemorrhoidectomy at an outpatient surgical center, the nurse instructs the patient to a. take prescribed pain medications before a bowel movement is expected. b. delay having a bowel movement for several days until healing has occurred. c. maintain a low-residue diet until the surgical area is healed. d. use ice packs on the perianal area to relieve pain and swelling.
A Rationale: Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement. Delay of bowel movements is likely to lead to constipation. A high-residue diet will increase stool bulk and prevent constipation. Sitz baths are used to relieve pain and keep the surgical area clean. Cognitive Level: Application Text Reference: p. 1083 Nursing Process: Implementation NCLEX: Physiological Integrity
24. A patient newly diagnosed with Crohn's disease asks the nurse what to expect in the future. The best response by the nurse is, a. "You need to know that there is the probability of lifelong, unpredictable periods of remissions and recurrences." b. "You can expect to lead a normal life and may have long periods without episodes of diarrhea or other symptoms." c. "Most patients with Crohn's disease require an ostomy to control the disease, but you can adjust to that." d. "After about 10 years, patients with Crohn's disease have a high risk for colon cancer unless the colon is removed."
A Rationale: Crohn's disease has recurrent acute exacerbations that occur at unpredictable intervals. There are many lifestyle changes that patients need to make with regard to diet and medication use. The preference is to treat Crohn's disease with medications rather than with surgery. Patients with Crohn's disease are at high risk for cancer of the small intestine, but the risk for colon cancer is lower. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Physiological Integrity
35. After teaching a patient to irrigate a new colostomy, the nurse will determine that the teaching has been effective if the patient a. hangs the irrigating container about 18 inches above the stoma. b. stops the irrigation and removes the irrigating cone if cramping occurs. c. fills the irrigating container with 1000 to 2000 ml of lukewarm tap water. d. inserts the irrigation tubing no further than 4 to 6 inches into the stoma.
A Rationale: Irrigating container should be hung 18 to 24 inches above the stoma. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Evaluation NCLEX: Safe and Effective Care Environment
28. A recent colonoscopy revealed an increased number of polyps in a 22-year-old patient with a history of moderately severe familial adenomatous polyposis (FAP). In planning care for the patient, the nurse recognizes that the medical recommendation for patients with familial adenomatous polyposis includes a. a total colectomy with ileostomy. b. annual colonoscopy until age 40. c. routine periodic polypectomies via colonoscope to remove these abnormal growths. d. biannual colonoscopy for life because of a 50% chance of developing colon cancer.
A Rationale: Patients with FAP have a high likelihood of developing colorectal cancer by age 40; therefore, total colectomy with ileostomy is recommended for these patients. Frequent colonoscopy is required, but patients are encouraged to have a colectomy. Patients with FAP have too many polyps to be removed by polypectomy. The patient has an 80% chance of developing colorectal cancer. Cognitive Level: Application Text Reference: p. 1063 Nursing Process: Planning NCLEX: Health Promotion and Maintenance
11. A patient is brought to the emergency department with a knife impaled in the abdomen following a domestic fight. During the initial assessment of the patient, it is important for the nurse to a. assess the BP and pulse. b. remove the knife to assess the wound. c. determine the presence of Rovsing's sign. d. insert a urinary catheter and assess for hematuria.
A Rationale: The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing's sign is assessed in the patient with suspected appendicitis. A patient with a knife in place will be taken to surgery and assessed for bladder trauma there. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Assessment NCLEX: Physiological Integrity
1. A patient with acute diarrhea of 24 hours' duration calls the clinic to ask for directions for care. In talking with the patient, the nurse should a. ask the patient to describe the character of the stools and any associated symptoms. b. advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal (GI) motility. c. inform the patient that laboratory testing of blood and stool specimens will be necessary. d. advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.
A Rationale: The initial response by the nurse should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment. Cognitive Level: Application Text Reference: p. 1037 Nursing Process: Assessment NCLEX: Physiological Integrity
6. A patient is admitted to the emergency department with severe abdominal pain with rebound tenderness, anorexia, and chills. The vital signs include temperature 101° F (38.3° C), pulse 130, respirations 34, and blood pressure (BP) 82/50. Of the following collaborative interventions, which one should the nurse implement first? a. Infuse 1000 ml of lactated Ringer's solution over 30 minutes. b. Administer IV ketorolac (Toradol) 15 mg. c. Give IV ceftriaxone (Rocephin) 1 g. d. Obtain a computed tomography (CT) scan of the abdomen with and without contrast.
A Rationale: The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion. Cognitive Level: Application Text Reference: pp. 1044-1045 Nursing Process: Implementation NCLEX: Physiological Integrity
33. During the initial postoperative assessment of a patient's stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. The nurse should a. document the stoma assessment. b. notify the surgeon about the stoma appearance. c. monitor the stoma every 30 minutes. d. place an ice pack on the stoma to reduce swelling.
A Rationale: The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed. Cognitive Level: Application Text Reference: p. 1071 Nursing Process: Implementation NCLEX: Physiological Integrity
To palpate the liver during a head-to-toe physical assessment, the nurse a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.
ANS: A The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.
A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/minute in each quadrant d. Aortic pulsations visible in the epigastric area
ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. The other findings are within normal range for the physical assessment.
Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? a. 1 b. 2 c. 3 d. 4
ANS: B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen.
The nurse is assessing an alert and independent 78-year-old woman for malnutrition risk. The most appropriate initial question is which of the following? a. "How do you get to the store to buy your food?" b. "Can you tell me the food that you ate yesterday?" c. "Do you have any difficulty in preparing or eating food?" d. "Are you taking any medications that alter your taste for food?"
ANS: B This question is the most open-ended, and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.
Which information about an 80-year-old man at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion
ANS: B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.
A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6° F. d. The apical pulse is 104 beats/minute.
ANS: C A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.
After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies.
ANS: C After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.
While interviewing a 30-year-old man, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). The nurse will plan to assess the patient's knowledge about a. preventing noninfectious hepatitis. b. treating inflammatory bowel disease. c. risk for developing colorectal cancer. d. using antacids and proton pump inhibitors.
ANS: C Familial adenomatous polyposis is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP.
The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).
ANS: D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.
7. A 23-year-old woman is being evaluated in the emergency department for acute lower abdominal pain and vomiting. During the nursing history, the most helpful question by the nurse to obtain information regarding the patient's condition is a. "What type of foods do you usually eat?" b. "Can you tell me about your pain?" c. "What is your usual elimination pattern?" d. "Is it possible that you are pregnant?"
B Rationale: A complete description of the pain provides clues about the cause of the problem. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most. Cognitive Level: Application Text Reference: p. 1044 Nursing Process: Assessment NCLEX: Physiological Integrity
22. The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements for a patient who is hospitalized with an acute exacerbation of Crohn's disease, based on the finding of a. complaints of fatigue and weakness. b. hemoglobin of 10 g/dl (120 g/L). c. weight loss of 2 pounds (0.9 kg) in 2 days. d. a 1500-calorie intake over the last day.
B Rationale: A hemoglobin count of 10 g/dl indicates that the patient's iron and possibly protein intake are low. Fatigue and weakness may be due to the acute inflammatory response and to lack of rest because of frequent stools. A 2-pound weight loss over 2 days is not unusual in patients who are well nourished. A 1500-calorie diet may be sufficient to meet patient needs, depending on the patient's size. Cognitive Level: Application Text Reference: pp. 1053, 1059 Nursing Process: Diagnosis NCLEX: Physiological Integrity
5. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about the use of the drug, the nurse stresses that a. the use of this type of laxative is safe and adverse effects are very minimal. b. large amounts of fluid should be taken to prevent impaction or bowel obstruction. c. dietary sources of fiber should be eliminated to prevent excessive gas formation. d. fat-soluble vitamins must be taken because the drug blocks absorption of these vitamins.
B Rationale: A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives. Cognitive Level: Comprehension Text Reference: pp. 1042, 1044 Nursing Process: Implementation NCLEX: Physiological Integrity
21. A total proctocolectomy with a permanent ileostomy is performed for a patient with ulcerative colitis. The patient is very upset and tells the nurse, "I can not bear to even look at the stoma. I do not think I can manage all these changes." The nurse's best approach to the patient's remarks is to a. reassure the patient that care for the ileostomy will become easier. b. ask the patient if a member of an ostomy support group may visit. c. develop a detailed written plan for ostomy care for the patient. d. wait to intervene until the patient adjusts to the body image change.
B Rationale: A visitor from an ostomy support group who has had similar experiences may be helpful to the patient. In the response beginning, "reassure the patient," the nurse does not acknowledge the patient's feelings. The response beginning "develop a detailed written plan" also fails to acknowledge the patient's emotional response to the ostomy. The nurse should act to assist the patient with body image changes, not just wait for the patient to adjust as in the remaining response. Cognitive Level: Application Text Reference: p. 1075 Nursing Process: Implementation NCLEX: Psychosocial Integrity
36. The nurse explains to a patient with a new ileostomy that after the bowel adjusts to the ileostomy, the usual drainage will be about a. 1 cup. b. 2 cups. c. 3 cups. d. 1 quart.
B Rationale: After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 500 ml daily. Cognitive Level: Comprehension Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Physiological Integrity
39. A 42-year-old patient recently developed abdominal distention, weight loss, steatorrhea, and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The nurse determines that teaching about the treatment of the disease has been effective when the patient says, a. "I must take folic acid for the rest of my life." b. "I will avoid dietary wheat, rye, barley, and oats." c. "I will be sure to take all of the ordered antibiotics." d. "I should eat only very low-fat or fat-free foods."
B Rationale: Avoidance of gluten-containing foods is the only treatment for celiac disease. Folic acid deficiency may occur, but once the inflammatory process is resolved, the patient will not need to take folic acid. Antibiotics are not helpful in the treatment of the inflammatory process. Avoidance of dietary fat is not necessary. Cognitive Level: Application Text Reference: p. 1081 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
2. A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will a. order a diet with no dairy products for the patient. b. place the patient in a private room with contact isolation. c. explain to the patient why antibiotics are not being used. d. teach the patient about proper food handling and storage.
B Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile. Cognitive Level: Application Text Reference: p. 1038 Nursing Process: Planning NCLEX: Safe and Effective Care Environment
16. While obtaining a nursing history from a patient with IBD, the nurse recognizes that the patient most likely has ulcerative colitis rather than Crohn's disease when the patient reports experiencing a. weight loss. b. bloody stools. c. abdominal pain and cramping. d. disease onset at age 20.
B Rationale: Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD. Weight loss, abdominal pain and cramping, and onset at age 20 are consistent with both Crohn's disease and ulcerative colitis. Cognitive Level: Comprehension Text Reference: p. 1051 Nursing Process: Assessment NCLEX: Physiological Integrity
43. A patient with Crohn's disease has a megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for a. oral ferrous sulfate tablets. b. cobalamin (B12) injections. c. iron dextran (Imferon) injections. d. regular blood transfusions.
B Rationale: Crohn's disease frequently affects the ileum, where absorption of vitamin B12 occurs and the B12 must be administered regularly by the IM route to correct the anemia. Iron deficiency does not cause megaloblastic anemia. The patient may need occasional transfusions but not regularly scheduled transfusions. Cognitive Level: Application Text Reference: pp. 1052-1053, 1056-1057 Nursing Process: Planning NCLEX: Physiological Integrity
25. A patient with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, foul-smelling urine. The nurse will teach the patient a. to clean the perianal carefully after any stools. b. about fistula formation between the bowel and bladder. c. to empty the bladder before and after sexual intercourse. d. about the effects of corticosteroid use on immune function.
B Rationale: Fistulas between the bowel and bladder occur in Crohn's disease and can lead to UTI. There is no information indicating that the patient's risk for UTI is caused by poor cleaning or not voiding before and after intercourse. Steroid use may increase the risk for infection, but the characteristics of the patient's urine indicate that a fistula has occurred. Cognitive Level: Application Text Reference: p. 1052 Nursing Process: Implementation NCLEX: Physiological Integrity
17. Sulfasalazine (Azulfidine) is prescribed for a patient who has been diagnosed with ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when the patient says, a. "The medication will prevent infections that cause the diarrhea." b. "The medication suppresses the inflammation in my large intestine." c. "I will need lab tests to be sure that I can still fight infections." d. "I will take the sulfasalazine as an enema or suppository."
B Rationale: Sulfasalazine suppresses the inflammatory process that causes the symptoms of ulcerative colitis. It is not used to treat infections. Laboratory tests for immune suppression are needed for the immunosuppressant medications used for ulcerative colitis. Sulfasalazine is an oral medication, although the active portion of the medication (5-ASA) may be given rectally. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Evaluation NCLEX: Physiological Integrity
12. A patient is admitted to the emergency department for evaluation of right lower-quadrant abdominal pain with nausea and vomiting. The patient has a white blood cell count (WBC) of 14,000/l with a shift to the left. Which of these actions is appropriate for the nurse to take? a. Encouraging the patient to take sips of clear liquids b. Applying an ice pack to the right lower quadrant c. Checking for rebound tenderness every 30 minutes d. Teaching the patient how to cough and deep breathe
B Rationale: The patient's clinical manifestations are consistent appendicitis, and application of an ice pack will decrease inflammation at the area. The patient should be NPO in case immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain and the patient is not likely to retain information at this point. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Implementation NCLEX: Physiological Integrity
38. The nurse identifies a nursing diagnosis of acute pain related to edema and surgical incision for a patient who has had a herniorrhaphy performed for an incarcerated inguinal hernia. An appropriate nursing intervention for this problem is to a. administer stool softeners as ordered. b. provide warm sitz baths several times a day. c. apply a scrotal support with application of ice. d. apply moist heat to the abdomen.
C Rationale: Because swelling is likely to affect the scrotum, a scrotal support and ice are used to reduce edema. Stool softeners will not decrease pain or swelling. Sitz baths or moist heat application will not reduce swelling or edema in the scrotal area. Cognitive Level: Application Text Reference: p. 1078 Nursing Process: Implementation NCLEX: Physiological Integrity
32. A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to a. teaching about a low-residue diet. b. monitoring drainage from the stoma. c. assessing the perineal drainage and incision. d. encouraging acceptance of the colostomy site.
C Rationale: Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period. Cognitive Level: Application Text Reference: p. 1068 Nursing Process: Planning NCLEX: Physiological Integrity
31. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to a. identify the extent of cancer spread or metastasis. b. confirm the diagnosis of colon cancer. c. monitor the tumor status after surgery. d. determine the need for postoperative chemotherapy.
C Rationale: CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on other factors than CEA. Cognitive Level: Comprehension Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity
23. A 26-year-old patient is diagnosed with Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach the patient about a. activity restrictions. b. fluid restriction. c. oral corticosteroids. d. enteral feedings.
C Rationale: Corticosteroids are used to achieve remission in IBD, and systemic corticosteroids will be used in Crohn's disease to affect the small intestine. Decreased activity level is indicated only if the patient has severe fatigue and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral feedings. Cognitive Level: Application Text Reference: p. 1054 Nursing Process: Planning NCLEX: Physiological Integrity
34. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of the ileostomy, the nurse informs the patient about the need to a. restrict fluid intake to prevent constant liquid drainage from the stoma. b. change the pouch every day to prevent leakage of contents onto the skin. c. use care when eating high-fiber foods to avoid obstruction of the ileum. d. irrigate the ileostomy daily to avoid having to wear a drainage appliance.
C Rationale: High-fiber foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy. Patients with ileostomies lose the absorption of water in the colon and need to take in increased amounts of fluid. The pouch should be drained frequently but is changed every 5 to 7 days. The drainage from an ileostomy is liquid and continuous, so control by irrigation is not possible. Cognitive Level: Application Text Reference: p. 1073 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance
9. Following an exploratory laparotomy and bowel resection, a patient has an NG tube to suction but complains of nausea and stomach distention. The nurse irrigates the tube PRN as ordered, but the irrigating fluid does not return. The first action by the nurse should be to a. notify the patient's health care provider. b. auscultate for bowel sounds. c. reposition the tube and check for placement. d. remove the tube and replace it with a new one.
C Rationale: Repositioning the tube will frequently facilitate drainage. Because this is a common occurrence, it is not appropriate to notify the health care provider. Information about the presence of absence of bowel tones will not be helpful in improving drainage. Removing the tube and replacing it are unnecessarily traumatic to the patient. Cognitive Level: Application Text Reference: p. 1045 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment
46. When performing an admission assessment for a patient with abdominal pain, the nurse palpates the left lower quadrant and the patient complains of right lower quadrant pain. The nurse will document this as a. McBurney's point. b. rebound pain. c. Rovsing's sign. d. Cullen's sign.
C Rationale: Rovsing's sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. McBurney's point, rebound pain, and Cullen's sign are used to describe other aspects of the abdominal assessment. Cognitive Level: Application Text Reference: pp. 1047-1049 Nursing Process: Assessment NCLEX: Physiological Integrity
13. The nurse identifies the collaborative problem of potential complication: hypovolemic shock related to loss of circulatory volume for a patient with bacterial peritonitis resulting from a ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs as a result of a. prolonged nasogastric (NG) suctioning. b. increased production of stress hormones. c. extracellular fluid shift into the peritoneal cavity. d. loss of purulent drainage into the peritoneal cavity.
C Rationale: The inflammatory process causes the shift of fluids into the peritoneal space. Patients with NG suctioning receive IV fluids to compensate for fluid loss. Stress hormone production causes retention of fluids. Purulent drainage is not usually a significant source of fluid loss. Cognitive Level: Application Text Reference: p. 1049 Nursing Process: Diagnosis NCLEX: Physiological Integrity
4. A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." The most appropriate nursing action at this time is to a. encourage the patient to drink at least 3000 ml of fluid a day. b. inform the patient that a daily bowel movement is not necessary. c. perform a focused nursing assessment to identify risk factors for constipation. d. suggest that the patient increase dietary intake of foods that are high in fiber.
C Rationale: The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment. Cognitive Level: Application Text Reference: pp. 1042-1043 Nursing Process: Implementation NCLEX: Physiological Integrity
42. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea. The nurse anticipates that the patient will need to a. prepare for colonoscopy by taking laxatives. b. have blood drawn for blood cultures. c. bring a stool specimen in to be tested for C. difficile. d. schedule a barium enema to check for inflammation.
C Rationale: The patient's age and history of antibiotic use suggest a C. difficile infection. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema. Cognitive Level: Application Text Reference: pp. 1036-1037 Nursing Process: Planning NCLEX: Physiological Integrity
19. Surgery is recommended by the health care provider for a patient with severe ulcerative colitis. The patient asks the nurse for clarification about the various procedures and the associated advantages and disadvantages. In responding to the patient's concerns, the nurse explains that a. surgery for ulcerative colitis involves the formation of a temporary ileostomy to divert fecal contents until the large bowel heals. b. in a total proctocolectomy with a continent ileostomy, a pouch is created that holds bowel contents and is emptied once a day with the use of a catheter. c. a total colectomy and ileal reservoir provide the most normal elimination function, but this surgery consists of two procedures, requiring a temporary ileostomy for 8 to 12 weeks. d. any proposed surgery for treatment of ulcerative colitis should be given serious consideration because the disease often recurs in previously unaffected parts of the bowel.
C Rationale: The total colectomy and ileal reservoir enable the patient to pass stool rectally but require two procedures 8 to 12 weeks apart. Although a temporary ileostomy may be needed, the large bowel is removed rather than being allowed to heal. The pouch formed during total proctocolectomy with continent ileostomy is drained more often than once daily. Surgical treatment for ulcerative colitis is curative because the colon is removed. Cognitive Level: Application Text Reference: p. 1055 Nursing Process: Implementation NCLEX: Physiological Integrity
18. The nurse identifies a nursing diagnosis of impaired skin integrity related to having 15 to 20 daily episodes of diarrhea for a patient with ulcerative colitis. The nurse recognizes that teaching regarding perianal care has been effective when the patient a. takes a sitz bath for 40 minutes following each stool. b. asks for antidiarrheal medication after each diarrhea stool. c. uses witch hazel compresses to provide relief from anal irritation. d. cleans the perianal area with soap and water after each stool.
C Rationale: Witch hazel compresses are suggested to reduce anal irritation and discomfort. Sitz baths may be helpful but should be limited to 15 or 20 minutes. Antidiarrheal medications are not given 15 to 20 times a day. The perianal area should be washed with water after each stool. Cognitive Level: Application Text Reference: p. 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity
30. During preoperative preparation for a patient scheduled for an abdominal-perineal resection, the nurse will a. give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria. b. teach the patient that activities such as sitting at the bedside will be started the first postoperative day. c. instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal-anal reservoir. d. administer enemas and laxatives to ensure that the bowel is empty before the surgery.
D Rationale: A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection. Oral antibiotics are given to reduce colonic and rectal bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent colostomy is created with this surgery. Cognitive Level: Application Text Reference: p. 1066 Nursing Process: Implementation NCLEX: Physiological Integrity
27. A patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient, a finding by the nurse that is consistent with a large bowel obstruction includes a. metabolic alkalosis. b. referred pain to the back. c. bile colored vomiting. d. abdominal distension.
D Rationale: Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Referred back pain is not a common clinical manifestation of intestinal obstruction. Bile-colored vomit is associated with higher intestinal obstruction. Cognitive Level: Comprehension Text Reference: pp. 1061-1062 Nursing Process: Assessment NCLEX: Physiological Integrity
3. A patient who is hospitalized with a diagnosis of Giardia lamblia infection frequently has uncontrollable explosive diarrhea. The patient closes the eyes and will not talk to the nurse when the linens are changed and skin care is performed. To help maintain the patient's self-esteem, the nurse should a. use incontinence briefs for the patient so that the cleaning is less cumbersome and embarrassing. b. request an order for an antidiarrheal drug from the health care provider to help control the diarrhea episodes. c. ensure the patient that the lack of control is temporary and will resolve after about a week of treatment. d. acknowledge the behavior as reflective of a difficult situation and provide privacy during hygiene.
D Rationale: Acknowledging the difficulty of the situation and providing privacy will decrease the patient's embarrassment about the incontinence. Incontinence briefs are usually perceived as humiliating for patients. Use of antidiarrheal medications prolongs the exposure to the Giardia by slowing GI motility. Giardia may take several months to resolve. Cognitive Level: Application Text Reference: pp. 1039-1040 Nursing Process: Implementation NCLEX: Psychosocial Integrity
14. A patient diagnosed with irritable bowel syndrome (IBS) tells the nurse, "My friends tell me this problem is all in my head." In caring for the patient, the nurse should a. discuss the new medications that are available to treat the condition. b. inform the patient that IBS has a specific, identifiable cause. c. explain that modifications to increase dietary fiber can control the symptoms. d. encourage the patient to express feelings and ask questions about IBS.
D Rationale: Because psychologic and emotional factors can impact on the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Although new medications are available, discussion of these medications does not address the patient's concerns with what friends think or say. There is no specific cause for IBS. Modifications in fiber intake may help some patients but might also increase bloating and gas pain. In addition, discussion of fiber does not address the patient's feelings. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Implementation NCLEX: Psychosocial Integrity
26. A patient is hospitalized with severe vomiting and colicky abdominal pain that is somewhat relieved with the vomiting. The health care provider orders an IV infusion of lactated Ringer's solution and placement of an NG tube. An appropriate collaborative problem for the nurse to identify for the patient at this time is a. potential complication: volvulus. b. potential complication: thromboembolism. c. potential complication: renal insufficiency. d. potential complication: metabolic alkalosis.
D Rationale: Metabolic alkalosis is a complication of NG suction resulting from loss of HCl from the stomach. Volvulus and thromboembolism are not associated with NG placement. The patient is hydrated with IV fluids to avoid renal insufficiency or failure. Cognitive Level: Application Text Reference: pp. 1061-1062 Nursing Process: Diagnosis NCLEX: Physiological Integrity
29. While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse will be most concerned about a. lifelong constipation. b. nausea and vomiting. c. history of an appendectomy. d. recent blood in the stools.
D Rationale: Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication. Nausea and vomiting are not common clinical manifestations of problems with the distal GI tract. An appendectomy is not a risk factor for cancer of the colon. Cognitive Level: Application Text Reference: pp. 1064-1065 Nursing Process: Assessment NCLEX: Physiological Integrity
10. A patient is brought to the emergency department following an automobile accident in which blunt trauma to the abdomen occurred. The patient is splinting the abdomen and complaining of pain, and bowel sounds are decreased. Peritoneal lavage returns brown drainage. Based on the results of the lavage, the nurse plans for a. preparation for a paracentesis. b. administration of pain medications. c. continued monitoring of the patient's condition. d. immediate preparation of the patient for surgery.
D Rationale: Return of brown drainage suggests perforation of the bowel and the need for immediate surgery. Paracentesis is not a treatment for abdominal trauma and may spread infection. Administration of pain medication and/or continued monitoring may be indicated for a negative finding with peritoneal lavage. Cognitive Level: Application Text Reference: p. 1048 Nursing Process: Planning NCLEX: Physiological Integrity
20. After teaching a patient with IBD about recommended dietary modifications, the nurse identifies a need for further instruction when the patient chooses from the menu a. spaghetti with tomato sauce. b. poached eggs and crisp bacon. c. boiled shrimp and white rice. d. ham hocks and beans.
D Rationale: The patient is taught to avoid high-fiber foods such as beans. In addition, high-fat foods such as ham may trigger diarrhea in some patients. The other choices are appropriate for a patient with IBD. Cognitive Level: Application Text Reference: pp. 1057-1058 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance
44. After a patient with IBD has had dietary teaching, which food choice by the patient indicates that the teaching has been successful? a. Oatmeal with cream, whole wheat toast, and a banana b. Corn tortilla taco with chicken, lettuce, tomato, and cheese c. Roast beef, mashed potatoes, and a tossed green salad d. Chicken sandwich with mayonnaise on white bread
D Rationale: This choice is consistent with the appropriate high-protein, low-residue diet. Oatmeal, whole wheat toast, green salad, corn tacos, lettuce, and tomato are all high-fiber choices and likely to worsen symptoms. Cognitive Level: Application Text Reference: pp. 1056-1057, 1059 Nursing Process: Evaluation NCLEX: Physiological Integrity
