GI NCLEX style questions
Elevated serum amylase and lipase levels. Decreased CA+
Acute pancreatitis
A client with a colostomy has a prescription for irrigation of the colostomy. Which solution should the nurse use for the irrigation?
Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used.
A client is experiencing blockage of the common bile duct. Which food selection made by the client indicates the need for further teaching? 1.Rice 2.Whole milk 3.Broiled fish 4.Baked chicken
Whole milk ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Bile acids or bile salts are produced by the liver to emulsify or break down fats. Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum, thus preventing breakdown of fatty intake. Knowledge of this should direct you to option 2. Dairy products, such as whole milk, ice cream, butter, and cheese, are high in cholesterol and fat and should be avoided.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.
The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer?
A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the mid-epigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer.
A nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)?
Rebound tenderness may indicate peritonitis.
The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis?
Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.
A nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse interprets that which finding will support the diagnosis?
Elevated serum lipase level
Relevant labs
CBC, PT, Electrolytes, AST/ALT lever enzymes, Ammonia- hepatic function (sample must be kept on ice), Amylase/Lipase- pancreatic function, Billirubin- liver function, h. pylori, Stool tests (fecal occult blood tests- hemmocult & c diff testing)
The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a common causative factor in this client's disorder?
Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis.
Age related changes in GI?
Decreased HCI production, decreased peristalisis, distention and dilation of the pancreatic ducts, decrease in # & size of hepatic cells.
Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication?
Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome?
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed.
A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client?
NPO (nothing by mouth) status ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest.
A nurse is providing a simple overview of the anatomy of the liver and gallbladder for a client hospitalized with biliary obstruction. The nurse explains that normally the liver stores bile in the gallbladder and that the liver and gallbladder are connected together by which passageway?
The gallbladder receives bile from the liver through the cystic duc
A client with spinal cord injury (SCI) is participating in a bowel retraining program. The nurse develops a plan that is based in part on the knowledge that defecation is normally a result of which phenomena?
The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.
A client is experienced delayed gastric emptying. The nurse plans care, knowing that dysfunction of which structures is responsible for the client's symptoms?
The pyloric sphincter joins the stomach and the duodenum and is responsible for proper gastric emptying.
A hospitalized client is diagnosed with pancreatitis. The nurse plans care, knowing that production of which substance will be elevated in blood studies for this client?
The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion.
The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis?
"Does the pain in your stomach radiate to the back?"
The client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube attached to continuous gastric suction. The nurse determines that teaching has been effective if the client makes which statement?
"It will help to remove gas and fluids from my stomach and intestine." ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction.
The nurse teaches a preoperative client about the use of a nasogastric (NG) tube for the planned surgery. Which statement indicates to the nurse that the client understands when the tube can be removed in the postoperative period?
"When my bowels begin to function again, and I begin to pass gas."
Which signs and symptoms would the RN expect to access in the client diagnosed with diverticulitis?
LLQ pain and elevated temp
The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should give the client suggestions for foods to aid in symptom management that are in which diet types?
A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be gradually added to the diet.
The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs?
A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Ischemia of the stoma would be associated with a dusky or bluish color.
A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which item from the supply room?
A tube with a large lumen and an air vent is a Salem sump tube.
A client with ulcerative colitis has a prescription to begin a salicylate medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication?
After meals ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Salicylate compounds such as sulfasalazine (Azulfidine) act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation.
In which optimal position should the nurse plan to place the client after bolus feeding using a nasogastric tube?
HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes
What chemicals do the parietal cells in the stomach secrete and what do they do?
Hydrochloric Acid: breaks down food for digestion. Intrinsic factor: needed for vit B12 absorption. Insufficient B12 can lead to pernicious anemia.
A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1.The pain is mostly around the umbilicus and comes and goes. 2.The pain increases when the client sits up and bends forward. 3.The pain usually increases after vomiting. 4.Eating helps to decrease the pain.
Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.
A nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?
Palpating for peripheral edema
A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body?
Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops.
The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?
Right upper quadrant, radiating to the right scapula and shoulder
A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis?
Severe and unrelenting, located in the epigastric area and radiating to the back
The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that the client understands the instructions if the client states the need to avoid which food?
The client with irritable bowel should take in a diet that consists of 30g to 40 g of fiber daily because dietary fiber will help produce bulky soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided.
The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4 to 6 weeks postoperatively?
For the first 4 to 6 weeks after colostomy formation, the client should consume a low-fiber diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, including those with fiber, one at a time to determine tolerance to that food.
The nurse is preparing to insert a nasogastric (NG) tube as prescribed for the purpose of stomach decompression. The nurse reviews the health care provider's (HCP) prescriptions and anticipates that the HCP will prescribe which type of suction pressure and control?
Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
Malaise ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client?
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the client avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will increase comfort and decrease bleeding.
A nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription should the nurse confirm?
The client with acute pancreatitis is placed on an NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake.
The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
PQRST
Precipitating? What brings it on? What makes it better? Worse? When did you first notice it? Quality/quantity? How does it look, feel or sound? How intense/severe is it? Region/Radiation? Where is it? Does it spread? Severity scale? Scale 1-10 Timing? Onset, duration.
A nurse is reviewing laboratory test results for a client with liver disease and notes that the client's albumin level is low. The nurse next assesses the client for which physiological effect of decreased circulating albumin?
Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema.
A client with liver dysfunction is having difficulty with protein metabolism. The nurse checks the laboratory results, expecting that the results of which serum laboratory values will be elevated?
Ammonia
A client is experiencing blockage of the common bile duct. The nurse anticipates that the client's diet will be altered because the client will experience difficulty digesting which nutrient?
Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats.
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client?
Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed.
A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which complete proteins to maximize the availability of essential amino acids?
Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.
The nurse is caring for a client who had a subtotal gastrectomy. The nurse should assess the client for which signs and symptoms of dumping syndrome?
Dumping syndrome occurs after gastric surgery because food is not held long enough in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular and gastrointestinal symptoms. Signs and symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.
Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose?
Evaluate absorption of the last feeding. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All stomach contents are aspirated and measured before a tube feeding is administered. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of an enteral feeding to a full stomach could result in overdistention, predisposing the client to regurgitation and possible aspiration.
A client has been advanced to a solid diet after undergoing a subtotal gastrectomy. The nurse caring for the client would perform which action to minimize the risk of dumping syndrome?
Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying.
A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
Increase intake of fluids, including juices. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.
A nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, should the nurse question? 1.Digoxin (Lanoxin) 2.Furosemide (Lasix) 3.Indomethacin (Indocin) 4.Propranolol hydrochloride (Inderal LA)
Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide (Lasix) is a loop diuretic. Propranolol (Inderal) is a β-adrenergic blocker. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.
The nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse will direct the assessment to look for which as a hallmark sign of this disorder?
Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents.
A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse should anticipate that the client will be treated with which substance?
Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of monthly injections of vitamin B12. Iron is administered for iron deficiency anemia. Thiamine is most often prescribed for the client with alcoholism and folic acid is prescribed for folic acid deficiency.
Abdominal examination order of listening per our book
RUQ (Liver, Gallbladder, Duodenum, head of pancreas, hepatic flexure of colon, part of ascending and transverse colon) LUQ ( L lobe of liver, stomach, spleen, body and tail of pancreas, splenic flexure of the colon, part of transverse and descending colon) LLQ (part of descending, sigmoid colon, L ureter, L ovary and fallopian tube) RLQ ( Cecum, Appendix, R ureter, R ovary and fallopian tube)
A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ)? LLQ, RLQ, LUQ, RUQ LUQ, LLQ, RUQ, RLQ RLQ, LLQ, RUQ, LUQ RUQ, LUQ, RLQ, LLQ
RUQ, LUQ, RLQ, LLQ Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, LLQ, RLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence to prevent the client from tensing abdominal muscles because of the pain, which would make the examination difficult. Therefore, the LLQ would be the last area assessed for this client.
Sulfasalazine (Azulfidine) is prescribed for a client with a diagnosis of ulcerative colitis, and the care unit nurse instructs the client about the medication.
Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved.
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority; in addition, the vital signs should be checked before performing this procedure.
The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan?
The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.
A nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position?
To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy.
A client with gastric hypersecretion is scheduled for surgery. The nurse teaches the client that the procedure will lessen the stomach's production of acid by altering which structure?
Vagus nerve
The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list?
Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data should alert the nurse to this occurrence?
An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?
Assessing for the return of the gag reflex
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.
A nurse is caring for a hospitalized client who has been diagnosed with pancreatitis. The nurse checks the laboratory results form, anticipating that which enzyme will remain normal in the client?
Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.
The nurse is assisting a client with Crohn's disease to ambulate to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease?
Loose, watery stool
The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
Continuing to advance the tube to the desired distance ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.
The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record?
Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity.
A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation Examines the RUQ of the abdomen last Has the client lie in a supine position with legs straight and arms at the sides Views the abdomen by looking directly down while standing over the client's abdominal area
Examines the RUQ of the abdomen last If the client reports pain in the RUQ, the nurse would examine this area last in the examination sequence. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult. The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent, while keeping the arms at the sides to prevent tensing of the abdominal muscles. It is best to inspect the abdomen by standing at the side of the bed and then looking down on the abdomen, and also from the side at eye level.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider?
For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish brown color. The presence of bile may cause a green tinge. The health care provider (HCP) should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
The nurse is caring for a client who is receiving bolus feedings via a nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat for sleep. The nurse understands that which is the most appropriate position for this client at this time?
Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for 60 minutes after a bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying and thus prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding.
A client has a routine sigmoidoscopy with a tissue biopsy. What complication is the nurse looking for in a postprocedure assessment? Excessive diarrhea Heavy bleeding Nausea and vomiting Severe rectal pain
Heavy bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider. Excessive diarrhea, nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy.
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep.
The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? Acute diarrhea Aortic aneurysm Intestinal obstruction Pancreatitis
Intestinal obstruction Peristaltic movements are rarely seen except in thin clients and should be reported since the finding may indicate an intestinal obstruction. Acute diarrhea does not cause visible peristaltic movements. Aortic aneurysm may cause a bulging, pulsatile mass. Pancreatitis is characterized by severe pain.
A client who has had a gastrectomy is not producing sufficient intrinsic factor. The nurse plans care, knowing that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in which abdominal structure?
Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine.
A nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000 cells/mm3 with an increased number of immature WBCs. *Normal WBC 4,500-10,000
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?
Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells).
A client has been diagnosed with gastroesophageal reflux disease (GERD). The nurse plans care, knowing that the client has dysfunction of which part of the digestive system?
Lower esophageal sphincter (LES)
A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet at this time?
Protein ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.
A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing.
A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal system?
The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum.
The nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse should make which suggestion to the client?
The client at risk for dumping syndrome should be instructed to maintain a low Fowler's position while eating and lie down for at least 30 minutes after eating. The client also should be told that small, frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome.
A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which nursing action is appropriate?
The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid.
The nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which statement, if made by the client, indicates an understanding of these measures?
The client should be taught to include deodorizing foods in the diet such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?
The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client?
The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.
A client with acute ulcerative colitis requests a snack. Which would be the most appropriate snack for this client?
The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.
A nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement?
The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour.
The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign/symptom is most consistent with the typical presentation of duodenal ulcer?
The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the midepigastric area
The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings?
There are three stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.
A nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food?
Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals.
The clinic nurse is performing an abdominal assessment on a client and preparing to auscultate bowel sounds. The nurse should place the stethoscope in which quadrant first?
To auscultate bowel sounds, the nurse should begin in the right lower quadrant, at the ileocecal valve area, because normally bowel sounds are always present there. The diaphragm end piece is used because bowel sounds are relatively high pitched. The stethoscope is held lightly against the skin because pressing too hard can stimulate more bowel sounds.
In performing a physical assessment of a client with a diagnosis of ulcerative colitis, the nurse should expect which finding?
Ulcerative colitis is an inflammatory disease of the large colon. The signs and symptoms of ulcerative colitis include diarrhea with up to 10 to 20 liquid bloody stools per day, weight loss, anorexia, fatigue, increased white blood cell count, increased erythrocyte sedimentation rate, dehydration, hyponatremia, and hypokalemia, not hypercalcemia. Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Strictures and fistulas are more commonly seen in Crohn's disease than in ulcerative colitis. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).
