Chapter 52: Assessment of the GI system
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?
Palpate the RUQ last
An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?
"Changes in your liver cause drugs to be metabolized differently."
The student nurse studying the gastrointestinal system understands that chyme refers to what?
Liquefied food ready for digestion
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best
Ask the client about shellfish allergies
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best?
Assess the clients gag reflex.
To promote comfort after a colonoscopy, in what position does the nurse place the client?
Left lateral
The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.)
•Ammonia: liver •Lipase: pancreas
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)
•Cholangitis •Pancreatitis •Perforation •Sepsis
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
•Colon cancer •Diverticulitis •Inflammatory bowel disease •Peptic ulcer disease
The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.)
•Colonoscopy every 10 weeks •Computed tomography (CT) colonography every 5 years
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)
•Decreased hydrochloric acid production •Diminished sensation that can lead to constipation •Fat not digested as well in older adults •Pancreatic vessels become calcified
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?
Enzyme-linked immunosorbent assay (ELISA) toxin A+B
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
Its a good thing I love orange and cherry gelatin.
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
Liver
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
Notify the provider immediately
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?
Provide physical stimulation
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?
Put on gloves prior to collecting the sample
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
Remind the client that a small amount of bleeding is possible.
