GI EAQ Quiz

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition?

Delayed wound healing Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period?

Keeping the client's skin around the stoma clean 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. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take?

Use gloves when removing the client's bedpan. The virus is present in the stool of clients with hepatitis A; therefore, standard precautions should be followed when handling excretions. The virus also may be present in urine and nasotracheal secretions. The Centers for Disease Control and Prevention (CDC) (Canada: Public Health Agency of Canada (PHAC)) indicate that only standard precautions are necessary when caring for a client who is positive for the presence of hepatitis A; if a client is incontinent or using an incontinence device, the CDC (Canada: PHAC) recommends that contact precautions be implemented. Bringing food to a client requires no precautions; however, disposable utensils should be used and utensils discarded following standard precautions because the client's nasotracheal secretions contain the virus. Hepatitis A usually is not transmitted via the air.

The home health nurse provides education to a client with cancer of the tongue who will begin gastrostomy feedings at home. Which statement by the client indicates teaching by the nurse is effective?

"Before I start the procedure, I will measure the residual volume." Measuring the residual volume establishes whether an adequate volume of the previous feeding was absorbed. If a residual exceeds the parameter identified by the healthcare provider or is over 200 mL, a feeding may be held. This prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. Weights are taken and reported weekly or monthly depending on the client's condition and clinical goals. A carbonated beverage may be used if the tube becomes clogged; it is not used routinely. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

A nurse is instructing a client with peptic ulcer disease (PUD) about the diet that should be followed during the acute phase. Which type of diet should the nurse stress?

Bland foods A bland, nonirritating diet is recommended during the acute symptomatic phase. During the acute phase, a regular diet can cause discomfort. Clients should be instructed to avoid substances that increase gastric acid secretion, such as coffee, tea, and cola. Bedtime snacks should be avoided because they may stimulate gastric acid secretion as well. Gluten-free foods do not decrease gastric acid secretion. Low-carbohydrate foods do not decrease gastric acid secretion.

A nurse assesses a client with the diagnosis of an intestinal obstruction in the descending colon. When auscultating the midabdomen, what should the nurse expect to hear?

Borborygmi Borborygmi are rapid, high-pitched bowel sounds that are indicative of the hyperperistalsis that occurs behind an intestinal obstruction. Tympany is not auscultated but percussed, and it is described as high pitched or musical because of the presence of gas. An aortic bruit is auscultated above the umbilicus; a renal bruit is heard laterally above the umbilicus. Neither bruit can be auscultated at the midabdomen, and neither is related to an intestinal obstruction. A pleural friction rub is heard in the chest; it is associated with inflamed lung pleura.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be?

Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

A nurse is caring for a client who had major abdominal surgery one day ago. What factor increases the risk of this client developing a wound dehiscence?

Client being overweight Being grossly overweight is a predisposing factor to wound dehiscence because of decreased vascularity and fragility of adipose tissue and the added tension on the suture line. Placement of a T-tube does not contribute to dehiscence; a T-tube helps remove bile from the common bile duct. The presence of excessive flatus causes discomfort, not dehiscence. If the client is receiving the antibiotics because of the presence of a wound infection, then the infection is the risk factor for wound dehiscence. Receiving steroids, not prophylactic antibiotics, increases the risk of dehiscence because steroids slow collagen synthesis necessary for wound healing.

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance?

Moist, red, and raised above the skin surface The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. The stoma should be moist, not dry; pale pink indicates a low hemoglobin level. Although some stomas can be flush with the skin, a raised stoma is more common. The stoma should be moist, not dry; purple indicates compromised circulation. A depressed stoma is retracted and unexpected. Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority?

Observe the client for increasing confusion. An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?

Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first?

Gather more data from the night nurse about the technique used Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history?

Partial gastrectomy Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. The beta cells of the pancreas are not involved in secretion of intrinsic factor. Dietary intake does not affect the production of intrinsic factor.

A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of what symptom?

Pruritus 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. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? Select all that apply.

Rye Oats Wheat Rye, oats, and wheat should be avoided because they are irritating to the gastrointestinal mucosa. Gluten is not found in rice or corn; therefore, these items do not have to be avoided.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Use lemon juice to season meat Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

An older client with diarrhea is admitted to the hospital from a nursing home. A stool specimen confirms a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The daughter of the client asks why her mother has been placed in a room with another client who is on isolation. How should the nurse respond?

"It is safe to place people with the same infection in one room." There is no need to separate one client with MRSA from another client with the same infection. MRSA infections are highly contagious. MRSA infections are resistant to most antibiotics, especially methicillin. Clients with the same infection can remain in the same room; contact precautions are necessary to protect visitors and staff members.

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. What action should the nurse take?

Consider this an expected event As a result of the trauma of surgery, some bleeding can be expected for four to five 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. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan?

Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis. Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).