Chapter 41: Upper GI Problems

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Hemoglobin (Hgb) 10.8 g/dL b. Temperature 102.1°F (38.9°C) c. Absent bowel sounds in all quadrants d. Scant nasogastric (NG) tube drainage

ANS: B An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery and do not require any urgent action.

A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent Helicobacter pylori infection.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."

ANS: B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

ANS: B The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

A 58-yr-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has had a small intestinal resection.

ANS: C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue

ANS: C A red, velvety patch suggests erythroplasia, which has a high incidence (>50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex).

Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly, but are not the highest priorities.

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I eat small meals during the day and have a bedtime snack." d. "I quit smoking several years ago, but I still chew a lot of gum."

ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

After change-of-shift report, which patient should the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy d. 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy

ANS: C This patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

An adult with Escherichia coli O157:H7 food poisoning is admitted to the hospital with bloody diarrhea and dehydration. Which prescribed action will the nurse question? a. Infuse lactated Ringer's solution at 250 mL/hr. b. Monitor blood urea nitrogen and creatinine daily. c. Administer loperamide (Imodium) after each stool. d. Provide a clear liquid diet and progress diet as tolerated.

ANS: C Use of antidiarrheal agents is avoided with this type of food poisoning. The other orders are appropriate.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected? Tinnitus Drowsiness Reduced hearing Sensation of falling

Drowsiness Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate? Iced tea Dry toast Hot coffee Plain yogurt

Dry toast Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Water is the initial fluid of choice. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring? Malnutrition Bile reflux gastritis Dumping syndrome Postprandial hypoglycemia

Dumping syndrome After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? Barium swallow Endoscopic biopsy Capsule endoscopy Endoscopic ultrasonography

Endoscopic biopsy Because of this patient's history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer.

The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved? Nausea Belching Epigastric pain Difficulty swallowing

Epigastric pain Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution? Sucralfate Cimetidine Omeprazole Metoclopramide

Omeprazole There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine.

The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? Zolpidem Ondansetron Dexamethasone Morphine sulfate

Ondansetron Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? Pallor and diaphoresis Ecchymotic peripheral IV site Guaiac-positive diarrhea stools Heart rate 90, respiratory rate 20, BP 110/60

Pallor and diaphoresis A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. An ecchymotic peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the ecchymotic site does not represent a decline in condition.

A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? Tremors Constipation Double vision Numbness in fingers and toes

Tremors Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis? "It would be beneficial for you to eliminate drinking alcohol." "You'll need to drink at least two to three glasses of milk daily." "Many people find that a minced or pureed diet eases their symptoms of PUD." "Taking medication will allow you to keep your present diet while minimizing symptoms."

"It would be beneficial for you to eliminate drinking alcohol." Alcohol increases the amount of stomach acid produced. so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD.

The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding? "Pasteurized juices and milk are safe to drink." "Alfalfa sprouts are safe if rinsed before eating." "Fresh fruits do not need to be washed before eating." "Ground beef is safe to eat if cooked until it is brown."

"Pasteurized juices and milk are safe to drink." Drink only pasteurized milk, juice, or cider. Ground beef should be cooked thoroughly. Browned meat can still harbor live bacteria. Cook ground beef until a thermometer reads at least 160° F. If a thermometer is unavailable, decrease the risk of illness by cooking the ground beef until there is no pink color in the middle. Fruits and vegetables should be washed thoroughly, especially those that will not be cooked. Persons who are immunocompromised or older should avoid eating alfalfa sprouts until the safety of the sprouts can be ensured.

The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection? "Eating raw cookie dough from the package is a great snack when you do not have time to bake." "Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time." "To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers." "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."

"When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate." The student who did not accept the pink hamburger and asked for a new bun and clean plate understood that the pink meat may not have reached 160°F and could be contaminated with bacteria. Improperly storing cooked foods, eating raw cookie dough from a refrigerated package, and only using one cutting board without washing it with hot soapy water between the chicken and salad vegetables could all lead to food poisoning from contamination.

Which patient would be at highest risk for developing oral candidiasis? A 74-yr-old patient who has vitamin B and C deficiencies A 22-yr-old patient who smokes 2 packs of cigarettes per day A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks A 58-yr-old patient who is receiving amphotericin B for 2 days

A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent's infection. Use of tobacco products leads to stomatitis, not candidiasis.

Vasopressin 0.1 unit/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse?

ANS: 15 There are 0.4 unit/1 mL. An infusion of 15 mL/hr will result in the patient receiving 0.1 units/min as prescribed.

The nurse is caring for a patient who develops watery diarrhea and a fever after prolonged omeprazole (Prilosec) therapy. In which order will the nurse take actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Contact the health care provider. b. Assess blood pressure and heart rate. c. Give the PRN acetaminophen (Tylenol). d. Place the patient on contact precautions.

ANS: D, B, A, C Proton pump inhibitors including omeprazole (Prilosec) may increase the risk of Clostridium difficile-associated colitis. Because the patient's history and symptoms are consistent with C. difficile infection, the initial action should be initiation of infection control measures to protect other patients. Assessment of blood pressure and pulse is needed to determine whether the patient has symptoms of hypovolemia or shock. The health care provider should be notified so that actions such as obtaining stool specimens and antibiotic therapy can be started. Tylenol may be administered but is the lowest priority of the actions.

The nurse will anticipate preparing an older patient who is vomiting "coffee-ground" emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion or return to surgery are needed (or both). Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

Which action should the nurse in the emergency department anticipate for a young adult patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach the adverse effects of acetaminophen (Tylenol).

ANS: A Patients with bloody diarrhea should have a stool culture for Escherichia coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

Which information will the nurse include when teaching adults to decrease the risk for cancers of the tongue and buccal mucosa? a. Avoid use of cigarettes and smokeless tobacco. b. Use sunscreen when outside even on cloudy days. c. Complete antibiotic courses used to treat throat infections. d. Use antivirals to treat herpes simplex virus (HSV) infections.

ANS: A Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not increase the risk for oral cancer, although chronic irritation of the oral mucosa does increase risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human papillomavirus (HPV) infection is associated with an increased risk, but HSV infection is not a risk factor for oral cancer.

A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.

ANS: B Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished after the IV fluids are initiated.

The nurse determines that teaching regarding cobalamin injections has been effective when the patient with chronic atrophic gastritis states a. "The cobalamin injections will prevent gastric inflammation." b. "The cobalamin injections will prevent me from becoming anemic." c. "These injections will increase the hydrochloric acid in my stomach." d. "These injections will decrease my risk for developing stomach cancer."

ANS: B Cobalamin supplementation prevents the development of pernicious anemia. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient has no breath sounds in the left anterior chest. c. The patient complains of 7/10 (0 to 10 scale) abdominal pain. d. The patient has hypoactive bowel sounds in all four quadrants.

ANS: B Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed, but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy? a. Reposition the NG tube if drainage stops. b. Elevate the head of the bed to at least 30 degrees. c. Start oral fluids when the patient has active bowel sounds. d. Notify the doctor for any bloody nasogastric (NG) drainage.

ANS: B Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

A 26-yr-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications.

ANS: B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

The nurse and a licensed practical/vocational nurse (LPN/LVN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/LVN requires that the nurse intervene? a. The LPN/LVN uses soft swabs to provide oral care. b. The LPN/LVN positions the head of the bed in the flat position. c. The LPN/LVN includes the enteral feeding volume when calculating intake. d. The LPN/LVN encourages the patient to use pain medications before coughing.

ANS: B The patient's bed should be in Fowler's position to prevent reflux and aspiration of gastric contents. The other actions by the LPN/LVN are appropriate.

A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

ANS: B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective? a. "I will drink more liquids with my meals." b. "I should choose high carbohydrate foods." c. "Vitamin supplements may prevent anemia." d. "Persistent heartburn is common after surgery."

ANS: C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery, and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

After the nurse has completed teaching a patient with newly diagnosed eosinophilic esophagitis about the management of the disease, which patient action indicates that the teaching has been effective? a. Patient orders nonfat milk for each meal. b. Patient uses the prescribed corticosteroid inhaler. c. Patient schedules an appointment for allergy testing. d. Patient takes ibuprofen (Advil) to control throat pain.

ANS: C Eosinophilic esophagitis is frequently associated with environmental allergens, so allergy testing is used to determine possible triggers. Corticosteroid therapy may be prescribed, but the medication will be swallowed, not inhaled. Milk is a frequent trigger for attacks. NSAIDs are not used for eosinophilic esophagitis.

Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

A young adult been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)? a. Auscultate the bowel sounds. b. Assess for signs of dehydration. c. Assist the patient with oral care. d. Ask the patient about the nausea.

ANS: C Oral care is included in UAP education and scope of practice. The other actions are all assessments that require more education and a higher scope of nursing practice.

A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient? a. Sucralfate (Carafate), nystatin, and bismuth (Pepto-Bismol) b. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine c. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) d. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix)

ANS: C The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena

ANS: C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

A 58-yr-old woman who was recently diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

ANS: C This response is open ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. The response beginning, "It is important that you be realistic" discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

When a patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures.

ANS: D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals.

An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)

ANS: D Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids.

A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals.

ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

A 73-yr-old patient is diagnosed with stomach cancer after an unintended 20-lb weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. a family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used? Antibiotic(s), antacid, and corticosteroid Antibiotic(s), aspirin, and antiulcer/protectant Antibiotic(s), proton pump inhibitor, and bismuth Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

Antibiotic(s), proton pump inhibitor, and bismuth To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? Offer the patient an herbal supplement such as ginseng. Apply a cool washcloth to the forehead and provide mouth care. Take the patient for a walk in the hallway to promote peristalsis. Discontinue any medications that may cause nausea or vomiting.

Apply a cool washcloth to the forehead and provide mouth care. Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. Keep the patient NPO for 2 hours before dressing changes. b. Give the ordered prochlorperazine before dressing changes. c. Administer the prescribed morphine sulfate before dressing changes. d. Avoid performing dressing changes close to the patient's mealtimes.

C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain. However, an antiemetic may be added later if the nausea persists despite pain management.

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin tablets. d. referral to a dentist for professional tooth cleaning.

C Candida albicans infections are treated with an antifungal such as nystatin. Peroxide rinses would be painful. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

A patient has a sliding hiatal hernia. What nursing intervention will reduce the symptoms of heartburn and dyspepsia? Keeping the patient NPO Putting the bed in the Trendelenburg position Having the patient eat 4 to 6 smaller meals each day Giving various antacids to determine which one works for the patient

Having the patient eat 4 to 6 smaller meals each day Eating smaller meals during the day will decrease the gastric pressure and symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenburg position is not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the health care provider's prescription, so this is not a nursing intervention.

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved? Diarrhea Heartburn Constipation Lower abdominal pain

Heartburn Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? Turn, deep breathe, cough, and use spirometer every 4 hours. Maintain an upright position for at least 2 hours after eating. NG will have bloody drainage and it should not be repositioned. Keep in a supine position to prevent movement of the anastomosis.

NG will have bloody drainage and it should not be repositioned. The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.

A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate? Providing IV fluids and inserting a nasogastric (NG) tube Administering oral bicarbonate and testing the patient's gastric pH level Performing a fecal occult blood test and administering IV calcium gluconate Starting parenteral nutrition and placing the patient in a high-Fowler's position

Providing IV fluids and inserting a nasogastric (NG) tube A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient's suspected diagnosis, and parenteral nutrition is not a priority in the short term.

After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective? Decreased blood pressure Absence of muscle tremors Relief of nausea and vomiting No further episodes of diarrhea

Relief of nausea and vomiting Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care? Back pain 3 or 4 hours after eating a meal Chest pain relieved with eating or drinking water Burning epigastric pain 90 minutes after breakfast Rigid abdomen and vomiting following indigestion

Rigid abdomen and vomiting following indigestion A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement? Weight gain of 1 kg in 1 week Administer tube feeding at 25 mL/hr. Consume 50% of clear liquid tray this shift. Monitor for tube for placement and gastrointestinal residual.

Weight gain of 1 kg in 1 week The goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. Administering feedings, monitoring tube placement, and tolerance are interventions used to achieve the goal.