Gastrointestinal System- Custom EVOLVE Quiz
A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is performed. Postoperatively, how often and for how long would the nurse take the client's vital signs? 1. Every 15 minutes for 2 hours 2. Every 30 minutes for 4 hours 3. Every hour for 8 hours 4. Every 2 hours for 12 hours
1. Every 15 minutes for 2 hours Rationale: Every 15 minutes for 2 hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; 2 hours after the procedure, the vital signs can be taken every 30 minutes instead of every 15 minutes if the client is stable. Every hour for 8 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.
A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? 1. Institute fall prevention and safety measures. 2. Evaluate coping skills. 3. Measure abdominal girth daily. 4. Test stool specimens for blood.
1. Institute fall prevention and safety measures. Rationale: High ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority. Although it is important to evaluate the client's coping skills, it is not the priority. Although measuring abdominal girth daily is done to monitor ascites, it is not the priority for a confused client; safety is the priority. Testing stool specimens for blood is not the priority; providing for client safety is the priority.
The nurse provides dietary education for a client with a high triglyceride level. The information includes a list of foods that are high in saturated fat. The nurse determines that the teaching is understood when the client avoids which food item in planning a menu? 1. Fruits 2. Grains 3. Red meat 4. Vegetable oils
3. Red meat Rationale: Red meat is high in dense saturated fats and should be avoided. Fruits do not contain saturated fats. Grains do not contain saturated fats. Vegetable oils contain unsaturated fats.
The nurse is caring for a client who is scheduled for gastric bypass to treat morbid obesity. To minimize clinical manifestations of dumping syndrome, the client will be placed on which type of dietary plan? 1. Low-residue, bland diet 2. Fluid intake below 500 mL 3. Small, frequent feeding schedule 4. Low-protein, high-carbohydrate diet
3. Small, frequent feeding schedule Rationale: Small feedings reduce the amount of bulk passing into the jejunum and reduce the fluid that shifts into the jejunum. Although a diet high in roughage may be avoided, a low-residue, bland diet is not necessary. Total fluid intake does not have to be restricted; however, fluids should not be taken immediately before, during, or after a meal because they promote rapid stomach emptying. Concentrated sweets pass rapidly out of the stomach and increase fluid shifts; the diet should be low in carbohydrates. Relatively high protein is needed to promote tissue repair.
The nurse is caring for a client with cholelithiasis. Which clinical manifestation would the nurse expect if the client develops obstructive jaundice? 1. Yellow sclera 2. Pain on urination 3. Dark brown stools 4. Coffee-ground emesis
1. Yellow sclera Rationale: Yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into blood. Bilirubin is carried to all body regions, including skin and mucous membranes. Pain on urination is not associated with obstructive jaundice, but dark brown urine is. Pain is experienced in the right upper quadrant because of spasm of the gallbladder, whether or not biliary obstruction occurs. The stools are clay-colored, not brown, because bile pigments are not present in the gastrointestinal tract; the common bile duct is obstructed. Coffee-ground emesis indicates gastric bleeding; it is not a sign of cholelithiasis with obstructive jaundice.
A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care would be implemented during the postoperative period? 1. Limiting fluid intake for several days 2. Withholding fluids for 72 hours 3. Having the client change the colostomy bag 4. Keeping the client's skin around the stoma clean
4. Keeping the client's skin around the stoma clean Rationale: If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection. Although oral fluids are withheld until peristalsis returns, it is essential that parenteral fluids be administered to replace the losses incurred by surgery. The client is often unable to accept the altered body image and must be given time to adjust before participating actively in self-care.
A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, which symptom does the nurse expect the client to report? 1. Pruritus 2. Diarrhea 3. Blurred vision 4. Bleeding gums
1. Pruritus Rationale: Itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.
A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? 1. Apple 2. Orange 3. Tomato 4. Grapefruit
1. Apple Rationale: Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic; they can decrease the pH of the stomach and irritate the gastrointestinal mucosa.
A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. Which nursing action is most important when caring for this client? 1. Turning the client onto the side 2. Measuring the amount of vomitus 3. Assessing the wound for dehiscence 4. Administering the prescribed antiemetic to the client
1. Turning the client onto the side Rationale: The side-lying position promotes drainage of emesis and secretions from the mouth, reducing the risk of aspiration. Although accurate assessment of intake and output is important, prevention of aspiration is the priority. Dehiscence is not probable at this time; it is more common 5 to 7 days after surgery. Although the antiemetic may prevent additional vomiting, the nurse's priority is to prevent aspiration.
The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step? 1. Wait until a family member is present. 2. Assess barriers to learning colostomy care. 3. Provide simple written instructions concerning the care. 4. Wait until the client has accepted the change in body image.
2. Assess barriers to learning colostomy care. Rationale: Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.
A client develops an intestinal obstruction. A nasogastric tube is inserted and connected to low, continuous suction. The nurse monitors the client for fluid volume deficit. Which clinical finding would the nurse expect if the client becomes dehydrated? 1. Retlessness 2. Constipation 3. Inelastic skin turgor 4. Increased blood pressure
3. Inelastic skin turgor
A client has a colostomy after surgery for cancer of the colon. Which postoperative nursing intervention maximizes skin integrity? 1. Empty the colostomy bag when it is three-fourths full. 2. Allow one-half inch between the stoma and the appliance. 3. Help the client remove the appliance on the first postoperative day. 4. Apply stoma adhesive around the stoma and then attach the appliance.
4. Apply stoma adhesive around the stoma and then attach the appliance. Rationale: Stoma adhesive protects the skin and helps keep the appliance attached to the skin. The appliance should be emptied when it is one-third to one-half full. Allowing one-half inch between the stoma and the appliance is too much space; the enzymes in feces can erode the skin. Initially the nurse should change the appliance; self-care usually is instituted more gradually, depending on the client's physical and emotional response to the surgery.
A client consumes 4 ounces of apple juice, 6 ounces of tea, and 8 ounces of chicken broth. How many mL of fluid will the nurse document the client ingested? Record your answer using a whole number. _____ mL
540 mL Rationale: 540 mL is a correct calculation. 4 ounces apple juice x 30 mL/ounce = 120 mL, 6 oz tea x 30 mL/ounce = 180 mL, and 8 oz chicken broth x 30 mL/ounce = 240 mL. 120 + 180 + 240 = 540 mL that the client has ingested.
A female client who had a colostomy recently is asking questions about how normal her life will be now that she has a colostomy. Which statement by the client indicates a need for further teaching? 1. "I wanted another child, and now pregnancy is not an option for me." 2. "I must allow extra time for irrigating my colostomy when traveling." 3. "It is good to know that I can swim every day after my incision heals." 4. "I'm glad I won't have to have special clothing and I can wear what I have."
1. "I wanted another child, and now pregnancy is not an option for me." Rationale: Pregnancy is possible; it should be determined whether the client is referring to physiological capability or emotional concern about sexual relationships. Extra time usually is necessary in an unfamiliar environment and should be calculated into traveling plans. Swimming is permitted; the water will not injure the stoma or intestine. There are no adaptations or restrictions on the types of clothing.
The nurse provides education to a client who is learning how to self-administer gastrostomy tube feedings and would include which instruction? 1. Administering water after the feeding is completed 2. Maintaining the supine position during the feeding 3. Heating the feeding solution to slightly above body temperature 4. Determining tube placement by instilling water before the feeding
1. Administering water after the feeding is completed Rationale: Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.
The nurse is reviewing the laboratory results of and collecting a health history from a client with a diagnosis of colitis. Which common clinical manifestation of colitis would the nurse expect? 1. Weight loss 2. Hemoptysis 3. Increased red blood cells 4. Decreased white blood cells (WBC)
1. Weight loss Rationale: The inflammatory process associated with colitis increases peristalsis, causing abdominal cramping, diarrhea, and weight loss. Coughing up blood from the respiratory tract (hemoptysis) is not associated with colitis. Anemia, not polycythemia, is associated with colitis. The WBC count may be increased, not decreased.
The nurse discusses the regaining of bowel control with a client who recently had surgery for a colostomy in the descending colon. Which is important to emphasize in the teaching? 1. Irrigation routine 2. Management of fluid intake 3. Progressive exercise program 4. Maintenance of a low-residue diet
1. irrigation routine Rationale: Colostomy irrigations done daily at the same time help establish a regular pattern of bowel evacuation. Although adequate fluid intake is important to prevent hard stools, it will not help the client regain bowel control. Progressive exercise has no relationship to bowel control for a client with a distal colostomy; however, exercise does help prevent constipation. A soft, low-residue diet is not necessary.
The nurse is caring for a client in the postanesthesia care unit immediately after the client had a subtotal gastrectomy. The nurse identifies small blood clots in the client's gastric drainage. Which action would the nurse take? 1. Clamp the tube. 2. Consider this an expected event. 3. Instill the tube with iced normal saline. 4. Notify the health care provider immediately.
2. Consider this an expected event. Rationale: Because of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. Clamping the tube will cause increased pressure on the gastric sutures from a buildup of gas and fluid. Iced saline rarely is used because it causes vasoconstriction, local ischemia, and a reduction in body temperature. Notifying the client's surgeon of this finding is not necessary; this is an expected occurrence.
The nurse is caring for a client with a nasointestinal tube in place. To maintain patency of the tube, which type of solution would the nurse instill? 1. Sterile water 2. Isotonic saline 3. Hypotonic saline 4. Hypertonic glucose
2. Isotonic Saline Rationale: Isotonic saline most closely resembles body fluids; it will not cause an imbalance by pulling fluids and electrolytes out of the intravascular compartment. Hypotonic solutions (including sterile water) will allow absorption of fluid into the intravascular compartment resulting in dilution of electrolytes and possible circulatory overload. Hypertonic solutions will draw fluids out of the intravascular compartment into the gastrointestinal tract; glucose provides a medium for bacterial growth.
After a subtotal gastrectomy for cancer of the stomach, a client develops dumping syndrome. The client asks the nurse, "What does that mean?" How would the nurse explain dumping syndrome? 1. It is nausea resulting from a full stomach. 2. It is the reflux of gastric contents into the esophagus. 3. It is the buildup of flatulence within the large intestine. 4. It is the rapid passage of concentrated fluid into the small intestine.
4. It is the rapid passage of concentrated fluid into the small intestine. Rationale: When high-osmotic fluid passes rapidly into the small intestine, it causes hypovolemia; this results in a sympathetic response of tachycardia, diaphoresis, and dizziness. The symptoms also are attributed to a sudden increase and subsequent decrease in blood glucose level. The stomach is not full; its contents rapidly empty into the jejunum. Reflux of gastric contents into the esophagus may occur with gastroesophageal reflux disease; dumping syndrome is associated with increased motility, involving the stomach and the jejunum. Buildup of flatulence within the large intestine usually is associated with paralytic ileus; dumping syndrome leads to increased intestinal motility.
A client is admitted to the hospital with ascites. The client reports drinking a fifth (750 mL) of vodka mixed in orange juice every day for the past 3 months. To assess the potential for withdrawal symptoms, which question is important for the nurse to ask the client? 1. "When was your last drink of vodka?" 2. "What prompts your drinking episodes?" 3. "Do you also eat when you drink?" 4. "Why do you mix the vodka with orange juice?"
1. "When was your last drink of vodka?" Rationale: The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when drinking will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.
During a tap water enema, a client reports abdominal cramps. Which action would the nurse take? 1. Clamp the tubing and allow the client to rest. 2. Reassure the client and continue the irrigation. 3. Pinch the tubing so that less fluid enters the colon. 4. Raise the irrigating container to complete the irrigation quickly.
1. Clamp the tubing and allow the client to rest. Rationale: Rapid instillation of fluid into the colon may cause abdominal cramps. By clamping the tubing, the nurse allows the cramps to subside so the irrigation eventually can be continued. Emotional support will not interrupt the physical response of abdominal cramps. Although pinching the tubing would lessen the fluid entering the colon and raising the irrigating container to complete the irrigation quickly might reduce the force of the fluid, neither of these will eliminate the flow of fluid completely. Increasing the force of flow will increase abdominal cramps.
The nurse is providing discharge teaching to a client who had an ileostomy. Which instruction would the nurse emphasize? 1. Informing the client about the ileostomy association 2. Telling the client whom to contact if assistance is needed 3. Encouraging the client to return to the workplace as soon as possible 4. Teaching the client the importance of irrigations to regulate bowel movements
2. Telling the client whom to contact if assistance is needed Rationale: The client should know there is help available, even though direct supervision is no longer provided. Informing the client about the ileostomy association and encouraging the client to return to the workplace are not the emphasis at this time. Ileostomies are not irrigated because stool is liquid.
A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate [DNR]." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? 1. "My doctor will know what to do." 2. "My family can make the decisions for me." 3. "If something happens to me, I do not want cardiopulmonary resuscitation [CPR]." 4. "If I have a heart attack, I do not want any medication."
3. "If something happens to me, I do not want cardiopulmonary resuscitation [CPR]." Rationale: The statement, "If something happens to me, I do not want CPR," specifically states that if cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want cardiorespiratory resuscitation. If a DNR order is signed by the client, cardiopulmonary resuscitation will not be instituted. The response, "My doctor will know what to do," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make health care decisions on the client's behalf. The response, "My family can make the decisions for me," reflects an advance directive (e.g., durable power of attorney for health care), wherein a client gives power to another person (agent, surrogate, or proxy) to make health care decisions on the client's behalf. The response, "If I have a heart attack, I do not want any medication," reflects an advance directive (e.g., living will), wherein the client directs treatment in accordance with personal wishes.
The nurse provides education related to the relationship between aerobic exercise and weight loss to a client who is obese. The nurse evaluates that teaching is effective when the client states which effect of exercise? 1. "It will decrease my appetite." 2. "It will decrease my metabolic rate." 3. "It will increase my lean body mass." 4. "It will increase my resting heart rate."
3. "It will increase my lean body mass." Rationale: Exercise builds skeletal muscle mass and reduces excess fatty tissue. Appetite may increase with exercise. The metabolic rate will increase with exercise. During aerobic exercise the heart rate will increase, but between periods of exercise the heart rate will return to normal.
A client with carcinoma of the colon is scheduled for an abdominoperineal resection. What would preparation for the surgery include? 1. Medications to promote diuresis 2. Fluid restriction to 1 L daily 3. Antibiotics to reduce intestinal bacteria 4. Abdominal exercises to facilitate recovery
3. Antibiotics to reduce intestinal bacteria Rationale: Except in an emergency, the client receives an intestinal antibiotic for several days preoperatively to reduce the amount of intestinal bacteria. Diuretics are not necessary unless prescribed for a preexisting problem. Fluids usually are restricted after midnight on the day of surgery, not for days before surgery. Abdominal exercises are not part of the surgical preparation.
A client is diagnosed with chronic pancreatitis. Which dietary instruction is important for the nurse to share with the client? 1. Eat a low-fat, low-protein diet. 2. Avoid foods high in carbohydrates. 3. Avoid ingesting alcoholic beverages. 4. Eat a bland diet with no snacks in between.
3. Avoid ingesting alcoholic beverages. Rationale: Alcohol will cause the most damage. It increases pancreatic secretions, which cause autodigestion of the pancreas, leading to severe pain. Although the diet should be low in fat, it should be high in protein; also, it should be moderate in carbohydrates. The client should consume a sufficient amount of complex carbohydrates each day to maintain weight and promote tissue repair. A bland diet can be consumed, but snacks high in calories also are recommended.
A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. A diagnosis of gastric ulcer is made. Which is the primary nursing concern? 1. Chronic pain 2. Risk for injury 3. Electrolyte imbalance 4. Inadequate gas exchange
3. Electrolyte imbalance Rationale: The stomach produces about 3 L of secretions per day. Fluid lost through vomiting can produce inadequate fluid volume and electrolyte imbalance, which can lead to dysrhythmias and death. Although pain is associated with gastric ulcers and requires intervention, it is not life threatening as an electrolyte imbalance would be. Although the risk for injury is a concern, it is not the priority. Although respirations may be shallow when the client is experiencing pain, this is not the priority.
A client has circumgastric banding, a bariatric surgical procedure. The nurse provides discharge teaching about signs and symptoms of dumping syndrome and includes which physiological response? 1. Fever 2. Vomiting 3. Palpitations 4. Constipation
3. Palpitations Rationale: Dumping syndrome is caused by a rapid emptying of gastric contents into the small intestine, resulting in a constellation of vasomotor responses, including tachycardia, vertigo, syncope, diaphoresis, and pallor. Fever is a sign of infection, not dumping syndrome. Vomiting is not a sign of dumping syndrome; excessive food intake may result in nausea and vomiting. Diarrhea and abdominal cramping occur, not constipation.
