Gastrointestinal Disorders NCLEX 3000

Locate the abdominal quadrant where the nurse would expect to palpate the liver.

The liver is located in the right upper abdominal quadrant.

One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?

1. "Atropine decreases salivation and gastric secretions."

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?

1. "Continue to take antacids, even if your symptoms subside."

A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:

1. "Tell me about your husband's alcohol usage."

A nurse is assigned to care for four clients. Which client should a nurse assess first?

1. A postoperative client who just returned from surgery and is vomiting

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

1. Acute pain related to biliary spasms

When preparing a client for a hemorrhoidectomy, the nurse should take which action?

1. Administer an enema as ordered.

While obtaining a client's medication history, the nurse learns that the client takes ranitidine (Zantac), as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should instruct the client to avoid taking a drug from which class with ranitidine?

1. Antacids

To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method?

1. Aspiration of gastric contents and testing for a pH less than 6

A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema?

1. Assist the client into the left-lateral Sims' position., 2. Lubricate the distal end of the rectal catheter., 6. Be sure to keep the solution container below 18" above bed level.

A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?

1. Atrophy of the gastric mucosa

The physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine?

1. Before the pain becomes severe

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

1. Blood supply to the stoma has been interrupted.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?

1. Change the tube feeding solutions and tubing at least every 24 hours.

Which infections require contact precautions?

1. Clostridium difficile, 3. Methicillin-resistant staphylococcus aureus

What is the primary nursing diagnosis for a client with a bowel obstruction?

1. Deficient fluid volume

A client with mild diarrhea, fever, and abdominal discomfort is being evaluated for inflammatory bowel disease (IBD). Which statement about IBD is true?

1. Diarrhea is the most common sign of IBD.

Which diagnostic test would be used first to evaluate a client with acute upper GI bleeding?

1. Endoscopy

A client is preparing to undergo abdominal paracentesis. Which nursing interventions should be performed before the procedure?

1. Explain the procedure to the client., 2. Make sure informed consent was obtained., 3. Instruct the client to void.

The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?

1. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma

While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client's family how to handle it at home, what should the nurse do?

1. Irrigate the tube with cola

A client is receiving a cleansing enema. During the procedure, the client reports abdominal cramping. What should the nurse do?

1. Lower the fluid bag so that the instillation slows.

A nurse is assigned the care of six clients and has the aid of a nursing assistant. Which task is appropriate for the nurse to delegate to the nursing assistant?

1. Measuring and recording nasogastric tube output

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?

1. Notify the physician.

A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure?

1. Peristomal skin irritation

When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern?

1. Promoting defecation

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?

1. Relieving abdominal pain

Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease?

1. To keep gastric pH at 3.0 to 3.5

A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis?

1. Transient epigastric pain radiating to the back and right shoulder, 2. Burning in the chest after eating fried foods, 3. Flatulence, 4. Nausea

When collecting data on a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

1. a canker sore of the oral soft tissues.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

1. auscultate bowel sounds.

The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:

1. destroys the odor-proof seal.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for:

1. diaphoresis, vomiting, and diarrhea.

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When monitoring TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

1. hyperglycemia.

While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery primarily to:

1. increase respiratory effectiveness.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

1. increasing fluid intake to prevent dehydration.

A client with amebiasis, an intestinal infection, is prescribed metronidazole (Flagyl). When teaching the client about adverse reactions to this drug, the nurse should mention:

1. metallic taste.

A 32-year-old male client with appendicitis is experiencing severe abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:

1. surgery.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:

1. yellow sclerae.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

2. "Avoid coffee and alcoholic beverages."

The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching is required?

2. "I need to use laxatives regularly to prevent constipation."

A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client says she's concerned that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best?

2. "I'm not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so."

A client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine's onset of action occur?

2. 15 to 30 minutes

After admission for acute appendicitis, a client undergoes an appendectomy. He complains of moderate postsurgical pain for which the physician prescribes pentazocine (Talwin), 50 mg by mouth every 4 hours. How soon after administration of this drug can the nurse expect the client to feel relief?

2. 15 to 30 minutes

The nurse must administer an enema to an adult client. The appropriate distance for inserting an enema into an average-sized adult is:

2. 3" to 4".

When a client resumes oral feedings after having gastric resection, the nurse watches for early manifestations of dumping syndrome. The vasomotor disturbances associated with this syndrome usually occur how soon after eating?

2. 5 to 30 minutes

The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?

2. Anticholinergic drugs

A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instructed to take which action?

2. Avoid caffeine and carbonated beverages., 4. Stop smoking., 5.Take antacids 1 hour and 3 hours after meals.

A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?

2. Decreased abdominal strength

The nurse is developing a plan of care for a client with hepatitis A. What is the main route of transmission of this hepatitis virus?

2. Feces

One day after undergoing a traditional cholecystectomy, a client is scheduled to stand at the bedside and walk. What should a nurse teach the client to do before standing and walking for the first time after surgery?

2. Flex her legs when moving to a sitting position.

An 86-year-old client with a history of atrial fibrillation takes 5 mg of warfarin (Coumadin) daily. Warfarin therapy makes the client at risk for which complications?

2. Hemorrhage, 3. Hepatitis, 5. Hematuria

A 58-year-old client with osteoarthritis is admitted to the hospital with peptic ulcer disease. Which findings are commonly associated with peptic ulcer disease?

2. History of nonsteroidal anti-inflammatory drug (NSAID) use, 3. Epigastric pain that's relieved by antacids, 5. Nausea and weight loss

The nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

2. Increased urine output

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

2. Inspection, auscultation, percussion, and palpation

A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone (Maalox TC) by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?

2. It has a short duration of action.

A client seeks medical attention after developing acute abdominal pain. Which action by the nurse would help ensure accurate auscultation of the client's bowel sounds?

2. Making sure the client's bladder is empty before auscultating

A client with severe abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicitis?

2. Obstruction of the appendix

When preparing a client, age 50, for surgery to treat appendicitis, the nurse assists in formulating a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix

Which condition is most likely to have a nursing diagnosis of Deficient fluid volume?

2. Pancreatitis

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

2. Positioning the client on the side with the knees flexed

A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?

2. Provide the client with information about an advance directive.

As part of a routine screening for colorectal cancer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period?

2. Red meat,. 3. Turnips, 4. Horseradish

A client is scheduled for bowel resection with anastomosis involving the large intestine. Because of the surgical site, the nurse assists in formulating the nursing diagnosis of Risk for infection. To complete the nursing diagnosis statement, which "related-to" phrase should be added?

2. Related to the presence of bacteria at the surgical site

After undergoing a liver biopsy, the client should be placed in which position?

2. Right lateral decubitus position

As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture (Kaopectate), 60 ml by mouth after each loose bowel movement, up to eight doses daily. The client asks the nurse how soon the medication will take effect. How should the nurse respond?

2. Within 30 minutes

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

2. anorexia, nausea, and vomiting.

The nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to avoid:

2. aspiration.

Following a liver transplant a client develops ascites. The nurse should teach the client to:

2. brace the abdomen with a pillow during coughing.

For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin sulfate (Mycifradin). The rationale for neomycin use in this client is to:

2. decrease the intestinal bacteria count.

When evaluating a client for complications of acute pancreatitis, the nurse would observe for:

2. decreased urine output.

For a client with cirrhosis, deterioration of hepatic function is best indicated by:

2. difficulty in arousal.

A client with gastroenteritis is admitted to an acute care facility with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:

2. enteric precautions must be continued.

The nurse is performing an assessment on a client who has developed a paralytic ileus. The client's bowel sounds will be:

2. hypoactive.

A client is admitted with suspected cirrhosis. During assessment, the nurse is most likely to detect:

2. muscle wasting.

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:

2. phytonadione (Mephyton).

The nurse is teaching a client about malabsorption syndrome and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the:

2. small intestine.

A client with peptic ulcer disease is prescribed aluminum-magnesium complex (Riopan). When teaching about this antacid preparation, the nurse should instruct the client to take it with:

2. water.

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine (Zantac). Before the client is discharged, the nurse should provide which instruction?

3. "Avoid aspirin and products that contain aspirin."

The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

3. "Maintain a high-carbohydrate, low-fat diet."

A client with acute diarrhea is prescribed paregoric, 5 ml by mouth up to four times daily, until the diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. How should the nurse respond?

3. "Within 1 hour"

A client who has been treated for diverticulitis is being discharged on oral propantheline bromide (Pro-Banthine). The nurse should instruct the client to take the drug at which times?

3. 30 minutes before meals and at bedtime

After checking the client's chart for possible contraindications, the nurse is administering meperidine (Demerol), 50 mg I.M., to a client with pain after an appendectomy. Which type of drug would contraindicate the use of meperidine?

3. A monoamine oxidase (MAO) inhibitor

A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?

3. Ineffective breathing pattern

A nurse approaches a client with an 0800 dose of his scheduled pancreatin. The client states, "I'm not going to take that medicine. It makes me nauseated." What should the nurse do first?

3. Instruct the client about the benefit of taking the medication.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?

3. Monitoring the client's weight every day

A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?

3. Move him to the next available window-side bed.

A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl (Duragesic) by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do?

3. Notify the client's physician.

A 53-year-old client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colonoscopy?

3. Observe the client closely for signs and symptoms of bowel perforation., 4. Monitor vital signs frequently until they're stable., 5. Inform the client that there may be blood in his stool and that he should report excessive blood immediately.

The nurse should expect to administer which vaccine to the client after a splenectomy?

3. Pneumovax 23

The nurse is caring for a client with cirrhosis. Which data collection findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

3. Purpura and petechiae

Which of the following is a warning sign of colon cancer?

3. Rectal bleeding

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

3. Standard precautions

A client comes to the emergency department complaining of acute GI distress. When obtaining the client's history, the nurse inquires about his family history. Which disorder has a familial basis?

3. Ulcerative colitis

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:

3. aspiration.

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client's stools to be:

3. black and tarry.

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:

3. collect the specimen in a sterile container.

A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:

3. inhibits contraction of the bile duct and gallbladder.

The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:

3. irrigate the NG tube gently with normal saline solution.

When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be:

3. maintaining fluid balance.

A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:

3. onto the bedpan.

A client who received an inhalation anesthetic during GI surgery experiences severe shivering postoperatively. In addition to providing extra blankets, the nurse should:

3. provide oxygen as prescribed.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:

3. wear gloves when caring for the client and wash her hands after touching the client.

A client with recent onset of epigastric discomfort is scheduled for an upper GI series (barium swallow). When teaching the client how to prepare for the test, which instruction should the nurse provide?

4. "Avoid eating or drinking anything for 6 to 8 hours before the test."

During a client-teaching session, which instruction should the nurse give to a client receiving kaolin and pectin (Kaopectate) for treatment of diarrhea?

4. "Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily."

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?

4. "I'll eat frequent, small, bland meals that are high in fiber."

A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response?

4. "You may have eaten contaminated restaurant food."

A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?

4. A client with bilateral blindness

The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

4. Administering I.V. fluids

A nurse is working with a nursing assistant, who is given the task of calculating three clients' intake and output at the end of the shift. When the nurse reviews the nursing assistant's work, she discovers inaccuracies in the nursing assistant's results. What should the nurse do?

4. Ask the nursing assistant to show her how she determined the results.

Which food should be included in a client's diet during the first 6 to 8 weeks after ileostomy surgery?

4. Banana

One year ago, a client was diagnosed with cirrhosis of the liver caused by alcohol abuse. Since then, he has been noncompliant with the prescribed protein-restricted diet. After a friend finds him semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he's diagnosed with hepatic encephalopathy. The physician prescribes lactulose (Cephulac), 200 g diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition is lactulose prescribed?

4. Constipation

Which medication should the nurse expect to administer to a client with constipation?

4. Docusate sodium (Colace)

The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client's response, the surgeon should collaborate with which health team member?

4. Enterostomal nurse

A nurse is irrigating an open wound of the abdomen. In which direction should she arrange for the irrigation solution to flow through the wound?

4. From the top inside of the wound, through the wound, and then out

When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?

4. Irritability and drowsiness

While palpating a client's right upper quadrant, the nurse would expect to find which of the following structures?

4. Liver

A client with left hemiparesis is having difficulty handling eating utensils. A nurse asks the physician to request a consult with which discipline?

4. Occupational therapy

A client is admitted to the health care facility with nausea, vomiting, and abdominal cramps and distention. Which test result is most significant?

4. Serum potassium level of 3 mEq/L

A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?

4. Sign the consent only if she sees the client sign it.

After taking an antacid, the client asks the nurse where antacids act in the body. How should the nurse respond?

4. Stomach

Which outcome indicates effective client teaching to prevent constipation?

4. The client reports engaging in a regular exercise regimen.

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

4. The client touches the altered body part.

A client is undergoing an extensive diagnostic workup for a suspected GI problem. The nurse discovers that the client has a family history of ulcer disease. Which blood type also is a risk factor for duodenal ulcers?

4. Type O

The nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:

4. alcohol abuse and smoking.

A client is in the late stage of cirrhosis. When planning the client's diet, the nurse should focus on providing increased amounts of:

4. carbohydrate.

A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:

4. cryoprecipitate and fresh frozen plasma.

The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

4. drink liquids only between meals.

The physician prescribes lactulose (Cephulac), 30 ml by mouth three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:

4. level of consciousness (LOC).

Alterations in hepatic blood flow resulting from a drug interaction also can affect:

4. metabolism and excretion.

A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained:

4. until three fecal cultures are negative for Shigella.

A client with cirrhosis is ordered to have a daily measurement of his abdominal girth. Identify the anatomical landmark where the tape measure should be placed when obtaining this measurement.

Abdominal girth should be measured at the umbilicus to obtain the most accurate measurement.