Hinkle 45: Digestive and Gastrointestinal Treatment Modalities, Chapter 40: Management of Patients with Gastric and Duodenal Disorders, CH 39 Management of Patients with Oral and Esophageal Disorders, Chapter 39: Management of Patients with Oral and…

A client with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the client's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?" B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?" D. "Do any of your family members have training in first aid?"

"Does anyone in your family have experience at giving injections?"

A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching? "I will eat two large meals a day instead of three." "I will start taking a nap after meals, when possible." "I will plan to sleep flat without pillows." "I will eliminate bothersome foods from my diet."

"I will eliminate bothersome foods from my diet."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat." B. "The pain begins right after I eat." C. "I know that my father and my grandfather both had ulcers." D. "I seem to have bowel movements more often than I usually do."

"My pain resolves when I have something to eat."

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician? 200 mL 225 mL 150 mL 175 mL

225 mL

A client has been prescribed a protein intake of 0.6 g/kg of body weight. The client weighs 154 pounds. The nurse calculates the daily protein intake to be how many grams? Enter the correct number ONLY.

42 Explanation: The client's weight of 154 pounds is equal to 70 kg. The client is to receive 0.6 g of protein for each 1 kg of body weight. 0.6 g/kg x 70 kg = 42 grams. pg.1228

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? A) Excess fluid volume B) Risk for imbalanced nutrition, more than body requirements C) Impaired urinary elimination D) Deficient fluid volume

A

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis? A) Staphylococcus aureus B) Pneumococcus C) Methicillin-resistant Streptococcus aureus (MRSA) D) Streptococcus viridans

A

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every A) shift. B) 12 hours. C) hour. D) 24 hours.

A

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? A) Fluid volume deficit B) Mucous membrane irritation C) A cardiac dysrhythmia D) Pulmonary complications

A

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? A) Monitoring the feeding closely. B) Flushing the feeding tube. C) Increasing the feeding rate. D) Lowering the head of the bed.

A

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? A) Allow the patient to sip water as the tube is being inserted. B) Spray the oropharynx with an anesthetic spray. C) Have the patient maintain a backward tilt head position. D) Have the patient eat a cracker as the tube is being inserted.

A

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to A) Elevate the head of the bed to 45 degrees. B) Check the residual volume before the feeding. C) Accurately assess the amount of fluid infused. D) Change the tube feeding container and tubing.

A

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? A) Provide frequent mouth care. B) Keep the feeding formula refrigerated. C) Flush the tube with water before adding the feedings. D) Ensure adequate hydration with additional water.

A

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure B) Chronic malabsorption of iron and vitamins A and C C) Reflux of bile into the distal esophagus D) A sudden release of peptides

A sudden release of peptides

A nurse is presenting a class at a bariatric clinic about the different types of surgical procedures offered by the clinic. When describing the implications of different types of surgeries, the nurse should address which of the following topics? Select all that apply. A) Specific lifestyle changes associated with each procedure B) Implications of each procedure for eating habits C) Effects of different surgeries on bowel function D) Effects of various bariatric surgeries on fertility E) Effects of different surgeries on safety of future immunizations

A) Specific lifestyle changes associated with each procedure B) Implications of each procedure for eating habits C) Effects of different surgeries on bowel function

The nurse is caring for a client receiving a tube feeding. Which assessments will the nurse prioritize for this client? Select all that apply. A) Signs of dehydration B) Placement of the tube C) Neurological assessment D) Blood glucose level E) Body weight

A, B, D, and E

The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply. A) Encourage the client to eat frequent, small, well-balanced meals. B) Encourage the client to eat later in the day before bedtime rather than early in the morning. C) Instruct the client to eat slowly and chew the food thoroughly. D) Inform the client to remain upright for at least 2 hours after meals. E) Instruct the client to avoid alcohol or tobacco products.

A, C, D, and E

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcohol B. Adopt a low-residue diet C. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery

A. Avoid drinking alcohol C. Avoid nonsteroidal anti-inflammatories

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Assess lung sounds bilaterally. Suction the oral cavity of the client. Obtain consent for the esophagogastroscopy. Administer prescribed morphine intravenously.

Assess lung sounds bilaterally.

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? Digestive enzyme mixed with warm water Cranberry juice Commercial enzyme product Air insufflation

Cranberry juice

A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is: A) Antispasmodics B) Antacids C) H2-receptor antagonists. D) Proton pump inhibitors.

D

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

Erosion of the lining of the stomach or intestine

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient? Feedings can be administered with the patient in the recumbent position. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is Irritating the epiglottis Passing into the esophagus Coiling in the client's mouth Inserted into the lungs

Inserted into the lungs

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed

Insertion of an NG tube for decompression

The nurse is planning care for a client with painful oral lesions. Which food should be included in the client's diet? Hot tea Pretzels Jell-O Chili

Jell-O

A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A. Ask the client's primary provider to liaise between the nurse and the client. B. Delegate care of the client to a colleague. C. Limit contact with the client in order to provide privacy. D. Make appropriate referrals to services that provide psychosocial support.

Make appropriate referrals to services that provide psychosocial support

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Monitoring the feeding closely. Flushing the feeding tube. Lowering the head of the bed. Increasing the feeding rate.

Monitoring the feeding closely.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? Ensure adequate hydration with additional water. Flush the tube with water before adding the feedings. Provide frequent mouth care. Keep the feeding formula refrigerated.

Provide frequent mouth care.

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

Providing the client with physical and emotional support

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.

Smokes one pack of cigarettes daily.

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis? Pneumococcus Streptococcus viridans Methicillin-resistant Streptococcus aureus (MRSA) Staphylococcus aureus

Staphylococcus aureus

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

Strategies for avoiding irritating foods and beverages

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? A. Gastric cancer does not cause signs or symptoms until metastasis has occurred. B. Adherence to screening recommendations for gastric cancer is exceptionally low. C. Early symptoms of gastric cancer are usually attributed to constipation. D. The early symptoms of gastric cancer are usually not alarming or highly unusual.

The early symptoms of gastric cancer are usually not alarming or highly unusual.

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred? The nurse has inadvertently inserted the tube into the trachea. The nurse has inserted a tube that is too large for the patient. This is a normal occurrence and the tube should be left in place. The tube is most likely defective and should be immediately removed.

The nurse has inadvertently inserted the tube into the trachea.

A patient with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the patient has a perforated ulcer? A) The patient has abdominal bloating that developed rapidly. B) The patient has a rigid, boardlike abdomen that is tender. C) The patient is experiencing intense lower right quadrant pain. D) The patient is experiencing dizziness and confusion with no apparent hemodynamic changes.

The patient has a rigid, boardlike abdomen that is tender.

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information? A. The possibility of surgery, chemotherapy and radiotherapy B. The possibility of needing a short-term or long-term colostomy C. The benefits of weight loss and exercise as tolerated during recovery D. The good prognosis for clients who are treated for gastric cancer

The possibility of surgery, chemotherapy and radiotherapy

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action? A) This medication will reduce the amount of acid secreted in your stomach. B) This medication will make the lining of your stomach more resistant to damage. C) This medication will specifically address the pain that accompanies peptic ulcer disease. D) This medication will help your stomach lining to repair itself

This medication will reduce the amount of acid secreted in your stomach.

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? Persistent loose stools, chills, hiccups after eating Weakness, diaphoresis, diarrhea 90 minutes after eating Abdominal distention, elevated temperature, weakness before eating Constipation, rectal bleeding following bowel movements

Weakness, diaphoresis, diarrhea 90 minutes after eating

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? Weakness, diaphoresis, diarrhea 90 minutes after eating Persistent loose stools, chills, hiccups after eating Constipation, rectal bleeding following bowel movements Abdominal distention, elevated temperature, weakness before eating

Weakness, diaphoresis, diarrhea 90 minutes after eating

A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated. C. Weight is maintained or gained. D. High calcium diet is consumed.

Weight is maintained or gained.

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method? Air auscultation X-ray visualization Measurement of exposed tubing pH measurement of aspirate

X-ray visualization

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? a) "It is a vent that prevents backflow of the secretions." b) "It works as a marker to make sure that the tube stays in place." c) "It acts as a siphon, pulling secretions into the clear tubing." d) "It helps regulate the pressure on the suction machine."

a) "It is a vent that prevents backflow of the secretions." Explanation: The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement. pg.1215

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? a) 30-mL b) 20-mL c) 5-mL d) 10-mL

a) 30-mL Explanation: When small-bore feeding tubes for continuous tube feedings are used and irrigated after administration of medications, a 30-mL or larger syringe is necessary, because the pressure generated by smaller syringes could rupture the tube. pg.1222

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). The nurse a) Attaches the fat emulsion tubing to a Y connector close to the infusion site b) Starts a peripheral IV site to administer the fat emulsion c) Stops the admixture while the fat emulstion infuses d) Connects the tubing for the fat emulsion above the 1.5 micron filter

a) Attaches the fat emulsion tubing to a Y connector close to the infusion site Explanation: An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter. pg.1228

The nurse is preparing to administer all of a patient's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes on the patient's medication administration record which of the following types of oral medication? a) Enteric-coated tablets b) Simple compressed tablets c) Soft gelatin capsules filled with liquid d) Buccal or sublingual tablets

a) Enteric-coated tablets Explanation: Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube. pg.1223

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? a) Excess fluid volume b) Risk for imbalanced nutrition, more than body requirements c) Deficient fluid volume d) Impaired urinary elimination

a) Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination. pg.1219

Rebound hypoglycemia is a complication of parenteral nutrition caused by which of the following? a) Feedings stopped too abruptly b) Fluid infusing rapidly c) Cap missing from the port d) Glucose intolerance

a) Feedings stopped too abruptly Explanation: Rebound hypoglycemia occurs when the feedings are stopped too abruptly. Hyperglycemia is caused by glucose intolerance. Fluid overload is caused by fluids infusing too rapidly. An air embolism can occur from a cap missing on a port. pg.1230

The nurse is to discontinue a nasogastric tube that had been used for decompression. The first thing the nurse does is a) Flush with 10 mL of water. b) Remove the tape from the nose of the client. c) Withdraw the tube gently for 6 to 8 inches. d) Provide oral hygiene.

a) Flush with 10 mL of water. Explanation: Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene. pg.1219

When assessing whether a patient is a candidate for home parenteral nutrition, which of the following would be important to address? Select all that apply. a) Health status b) Family support c) Telephone access d) Motivation for learning e) Marital status

a) Health status b) Family support c) Telephone access d) Motivation for learning Explanation: Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the patient's ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The patient's marital status is not important. pg.1232

The nurse is conducting discharge education for a patient who is to go home with parenteral nutrition (PN). The nurse sees that the patient understands the education when the patient indicates which of the following is a sign and/or symptom of metabolic complications? a) Loose, watery stools b) Decreased pulse rate c) Increased urination d) Elevated blood pressure

a) Loose, watery stools Explanation: When the patient indicates that loose watery stools are a sign/symptom of metabolic complications, the nurse evaluates that the patient understands the teaching of metabolic complications. Signs and symptoms of metabolic complications from PN include neuropathies, mentation changes, diarrhea, nausea, skin changes, and decreased urine output. pg.1233

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and makes a recommendation when noting the following: a) No land line; cell phone available and taken by family member during working hours b) Water of low pressure that can be obtained through all faucets c) Little food in the working refrigerator d) Electricity that loses power, usually for short duration, during storms

a) No land line; cell phone available and taken by family member during working hours Explanation: A telephone is necessary for the client receiving PN for emergency purposes. Water, refrigeration, and electricity are available, even if the circumstances are not optimal. pg.1232

The nurse is inserting a nasogastric tube and the patient begins coughing and is unable to speak. What does the nurse suspect has occurred? a) The nurse has inadvertently inserted the tube into the trachea. b) The nurse has inserted a tube that is too large for the patient. c) This is a normal occurrence and the tube should be left in place. d) The tube is most likely defective and should be immediately removed.

a) The nurse has inadvertently inserted the tube into the trachea. Explanation: To ensure patient safety, it is essential to confirm that the tube has been placed correctly. The tube tip may be in the esophagus, stomach, or small intestine, or inadvertently inserted in the lungs, most commonly in the right main bronchus. Inappropriate placement may occur in patients with decreased levels of consciousness, confused mental states, poor or absent cough and gag reflexes, or agitation during insertion. pg.1216

The nurse is teaching an unlicensed caregiver about bathing patients who are receiving tube feedings. Which of the following is the most significant complication related to continuous tube feedings? a) The potential for aspiration b) A disturbance in the sequence of intestinal and hepatic metabolism c) An interruption in fat metabolism and lipoprotein synthesis d) The interruption of GI integrity

a) The potential for aspiration Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis. pg.1219

The nurse is inserting a sump tube in a patient with Crohn's disease who is suspected of having a bowel obstruction. What does the nurse understand is the benefit of the gastric (Salem) sump tube in comparison to some of the other tubes? a) The tube is radiopaque. b) The tube is shorter. c) The tube can be connected to suction and others cannot. d) The tube is less expensive.

a) The tube is radiopaque. Explanation: The gastric (Salem) sump tube is a radiopaque (easily seen on x-ray), clear plastic, double-lumen nasogastric tube. pg.1215

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? a) When the residual is greater than 200 mL b) When the residual is between 50 and 80 mL c) When the residual is about 50 mL d) When the residual is about 100 mL

a) When the residual is greater than 200 mL Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients. pg.1222

Initially, which diagnostic should be completed following placement of a NG tube? a) X-ray b) pH measurement of aspirate c) Measurement of tube length d) Visual assessment of aspirate

a) X-ray Explanation: Initially an X-ray should be used to confirm tube placement. Subsequently, each time liquids or medications are administered, as well as once per shift for continuous feedings, a combination of three methods is recommended: measurement of tube length, visual assessment of aspirate, and pH measurement of aspirate. pg.1218

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. She has the following oral medications prescribed: furosemide (Lasix), digoxin, enteric coated aspirin (Ecotrin), and vitamin E. The nurse withholds a) enteric coated aspirin b) digoxin c) furosemide d) vitamin E

a) enteric coated aspirin Explanation: Simple compressed tablets (furosemide, digoxin) may be crushed and dissolved in water. Soft gelatin capsules filled with liquid (vitamin E) may be opened, and the contents squeezed out. Enteric coated tablets (enteric coated aspirin) are not to be crushed and a change in the form of the medications is required. pg.1223

Semi-Fowler's position is maintained for at least which timeframe following completion of an intermittent tube feeding? a) 2 hours b) 1 hour c) 90 minutes d) 30 minutes

b) 1 hour Explanation: The semi-Fowler's position is necessary for an NG feeding, with the patient's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for patients receiving continuous tube feedings. pg.1219

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? a) 6 b) 4 c) 8 d) 10

b) 4 Explanation: Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater. pg.1218

The nurse is to insert a postpyloric feeding tube. One way that the nurse can aid in placement past the pylorus is to a) Assist the client to drink 8 ounces of water. b) Administer prescribed metoclopramide (Reglan). c) Have the client lay on his left side. d) Instruct the client to swallow several times.

b) Administer prescribed metoclopramide (Reglan). Explanation: Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on his right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum. pg.1216

The nurse is caring for a patient who has dumping syndrome from high carbohydrate foods being administered over a period of less than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? a) Administer the feeding at a warm temperature to decrease peristalsis. b) Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. c) Administer the feeding by bolus to prevent continuous intestinal distention. d) Administer the feeding with about 100 mL of fluid to dilute the high carbohydrate concentration.

b) Administer the feeding with the patient in semi-Fowler's position to decrease transit time influenced by gravity. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time. pg.1223

The primary source of microorganisms for catheter-related infections include the skin and which of the following? a) IV fluid bag b) Catheter hub c) IV tubing d) Catheter tubing

b) Catheter hub Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day. pg.1231

A client with a feeding tube is to receive medication. The medication supplied is an enteric-coated tablet. Which of the following would be most appropriate? a) Sprinkle the contents of the opened tablet into the tube. b) Check with the pharmacist to see of a liquid form is available. c) Dissolve the tablet in water after crushing it. d) Give the tablet as is in its original state.

b) Check with the pharmacist to see of a liquid form is available. Enteric-coated tablets due to their formulation cannot be crushed. Rather the nurse would need to contact the pharmacist to see if there is a liquid form available. Some time-released tablet forms can be opened but cannot be crushed because doing so may release too much of the drug too quickly Giving the tablet as is in its original form would be inappropriate because it would not pass through the tube, thus not reaching its intended site for absorption. (less)

A nurse is providing home care to a patient receiving intermittent tube feedings. The patient wants to take an over-the-counter allergy medication. The medication would need to be given via feeding tube because the patient has difficulty swallowing. The nurse checks the medication and finds that it is a timed-release tablet. Which action by the nurse would be most appropriate? a) Have the patient mix it with the feeding formula after crushing the tablet. b) Check with the pharmacy for an alternative formulation for the drug. c) State that the patient cannot take the drug anymore. d) Tell the patient to dissolve the tablet in water to administer it.

b) Check with the pharmacy for an alternative formulation for the drug. Explanation: Timed-release medications should not be crushed. Rather, the nurse should check with the pharmacy to see if another formulation (eg, liquid) is available that can be used safely with a feeding tube. Dissolving the tablet in water, like crushing it, would affect the drug's action, possibly releasing too much of the drug too quickly. Stating that the patient cannot take the drug anymore is inappropriate. A change in formulation or possibly a change to another drug in an appropriate formulation would be appropriate. pg.1223

The patient is on a continuous tube feeding. The tube placement should be checked every a) hour. b) 24 hours. c) shift. d) 12 hours.

c) shift. Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings pg.1217

Which of the following medications requires the nurse to contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Soft gelatin capsules filled with liquid b) Enteric-coated tablets c) Buccal or sublingual tablets d) Simple compressed tablets

b) Enteric-coated tablets Explanation: Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change in the form of medication is necessary for patients with tube feedings. Simple compressed tablets may be crushed and dissolved in water for patients receiving oral medications by feeding tube. Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings. The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube. pg.1223

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? a) Pulmonary complications b) Fluid volume deficit c) Mucous membrane irritation d) A cardiac dysrhythmia

b) Fluid volume deficit Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate. pg.1219

A nurse is preparing to perform a dressing change to the site of a patient's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply. a) Sterile gauze pads b) Masks c) Skin antiseptic d) Clean gloves e) Extension set tubing f) Alcohol wipes

b) Masks c) Skin antiseptic f) Alcohol wipes a) Sterile gauze pads Explanation: When preparing to perform a dressing change to a central venous access site, sterile technique is essential. The nurse would need to gather masks (for self and the patient) to reduce the possibility of airborne contamination, sterile gloves, skin antiseptic such as tincture of 2% iodine or chlorhexadine, sterile gauze to clean the area, sterile water or saline to clean the area after cleaning with the skin antiseptic, and alcohol wipes to clean the catheter ports. Extension set tubing is not routinely changed with dressing or tubing changes. Sterile, not clean, gloves are used. pg.1229

Which of the following is caused by improper catheter placement and inadvertent puncture of the pleura? a) Air embolism b) Pneumothorax c) Fluid overload d) Sepsis

b) Pneumothorax Explanation: A pneumothorax is caused by improper catheter placement and inadvertent puncture of the pleura. Air embolism can occur from a missing cap on a port. Sepsis can be caused by the separation of dressings. Fluid overload is caused by fluids infusing too rapidly. pg.1231

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? a) Base of the neck b) Tip of patient's nose c) Tragus of the ear d) Tip of the xiphoid process

b) Tip of patient's nose Explanation: To measure the length of the nasogastric tube, the nurse first places the distal tip of the tubing at the tip of the patient's nose, extends the tube to the tragus of the ear, and then extends the tube straight down to the tip of the xiphoid process. pg.1216

The client cannot tolerate oral feedings due to an intestinal obstruction and is NPO. A central line has been inserted, and the client is being started on parenteral nutrition (PN). The nurse performs the following actions while the client receives PN (select all that apply): a) Cover insertion site with a transparent dressing that is changed daily. b) Weigh the client every day. c) Document intake and output. d) Use clean technique for all catheter dressing changes. e) Check blood glucose level every 6 hours.

b) Weigh the client every day. e) Check blood glucose level every 6 hours. c) Document intake and output. Explanation: When a client is receiving PN through a central line, the nurse weighs the client daily, checks blood glucose level every 6 hours, and documents intake and output. These actions are to ensure the client is receiving optimal nutrition. The nurse also performs activities to prevent infection, such as covering the insertion site with a transparent dressing that is changed weekly and/or prn and using sterile technique during catheter site dressing changes. pg.1228

The nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc. The priority nursing action is to a) give the tube feeding. b) reassess the residual gastric content in 1 hour. c) withhold the tube feeding indefinitely. d) notify the physician.

b) reassess the residual gastric content in 1 hour. Explanation: If the gastric residual exceeds 100 cc for 2 hours in a row, the physician should be notified. One observation of a residual gastric content over 100 cc does not have to be reported to the physician. If the observation occurs two times in succession, the physician should be notified. If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time. If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely. pg.1221

The nurse is administering a tube feeding to a patient via intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? a) 60 minutes b) 80 minutes c) 30 minutes d) 15 minutes

c) 30 minutes Explanation: Tube feedings administered via intermittent gravity drip should be administered over 30 minutes or longer. pg.1220

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? a) 1 b) 4 c) 6 d) 2

c) 6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline ( ? 6). pg.1218

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? a) 10 p.m. to 12 a.m. b) 8 p.m. to 10 p.m. c) 6 p.m. to 8 p.m. d) 4 p.m. to 6 p.m.

c) 6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m. pg.1222

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following would be least appropriate to use to unclog the tube? a) Commercial enzyme product b) Air insufflation c) Cranberry juice d) Digestive enzyme mixed with warm water

c) Cranberry juice Explanation: To unclog a feeding tube, air insufflation, digestive enzymes mixed with warm water, or a commercial enzyme product could be used. Cola and cranberry juice are no longer advocated for use in clearing a clogged tube. pg.1218

The nurse on an evidence-based practice council is making recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which of the following situations? a) Before drawing blood b) With continuous infusions c) Daily when not in use d) When the line is discontinued

c) Daily when not in use Explanation: Daily instillation of normal saline and dilute heparin flush when a nontunneled central catheter is not in use will maintain the line's patency. Continuous infusion maintains the patency of the line. Normal saline and heparin flushes should be used after each time blood is drawn in order to prevent clotting of blood within the line. Normal saline and heparin flush are not needed when a line is being discontinued. pg.1229

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome? a) Slowed heart beat b) Dry skin c) Diarrhea d) Hyperglycemia

c) Diarrhea Explanation: Clients with a gastrojejunostomy are at risk for developing the dumping syndrome when they begin to take solid food. This syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea, which result from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum. This concentrated solution in the gut draws fluid from the circulating blood into the intestine, causing hypovolemia. The drop in blood pressure can produce syncope. As the syndrome progresses, the sudden appearance of carbohydrates in the jejunum stimulates the pancreas to secrete excessive amounts of insulin, which in turn causes hypoglycemia. pg.1220

The patient is on a continuous tube feeding. How often should the tube placement be checked? a) Every hour b) Every 24 hours c) Every shift d) Every 12 hours

c) Every shift Explanation: Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. Checking for placement every 12 or 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. pg.1216

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? a) Have someone go to the pharmacy to obtain the new solution. b) Slow the current infusion rate so that it will last until the new solution arrives. c) Hang a solution of dextrose 10% and water until the new solution is available. d) Begin an infusion of normal saline in another site to maintain hydration.

c) Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency. pg.1232

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is a) Coiling in the client's mouth b) Irritating the epiglottis c) Inserted into the lungs d) Passing into the esophagus

c) Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nastogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea. pg.1216

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? a) Tape the tube to the head of the bed to avoid dislodgement. b) Irrigate only through the vent lumen. c) Keep the vent lumen above the patient's waist to prevent gastric content reflux. d) Maintain intermittent or continuous suction at a rate greater than 120 mm Hg.

c) Keep the vent lumen above the patient's waist to prevent gastric content reflux. Explanation: The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon. pg.1215

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. It is best for the nurse to a) Place the nasogastric tube to the level of the esophagus. b) Document the discontinuation of the nasogastric tube. c) Notify the surgeon about the tube's removal. d) Reinsert the nasogastric tube to the stomach.

c) Notify the surgeon about the tube's removal. Explanation: If the nasogastric tube is removed accidently in a client who has undergone esophageal or gastric surgery, it is usually replaced by the physician. Care is taken to avoid trauma to the suture line. The nurse will not insert the tube to the esophagus or to the stomach in this situation. The nurse needs to do more than just document its removal. The nurse needs to notify the physician who will make a determination of leaving out or inserting a new nasogastric tube. pg.1219

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care? a) Flush the tube with water before adding the feedings. b) Ensure adequate hydration with additional water. c) Provide frequent mouth care. d) Keep the feeding formula refrigerated.

c) Provide frequent mouth care. Explanation: Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

The most significant complication related to continuous tube feedings is a) a disturbance in the sequence of intestinal and hepatic metabolism. b) an interruption in fat metabolism and lipoprotein synthesis. c) the potential for aspiration, d) the interruption of GI integrity,

c) the potential for aspiration, Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis. pg.1219

A patient is receiving a continuous tube feeding via an open delivery system. The patient is to receive 480 mL in 24 hours. The maximum amount of formula in the bag should not exceed which amount? a) 120 mL b) 50 mL c) 240 mL d) 80 mL

d) 80 mL Explanation: When using an open delivery system, bacterial contamination is possible. Therefore, the amount of feeding formula in the bag should never exceed what should be infused in a 4-hour period. In this case that amount would be 80 mL. (480 mL divided by 24 hours equals 20 mL per hour. 20 mL times 4 hours equals 80 mL.) pg.1223

A nurse is caring for a patient receiving parenteral nutrition at home. The patient was discharged from the acute care facility 4 days ago. Which of the following would the nurse include in the patient's plan of care? Select all that apply. a) Daily transparent dressing changes b) Intake and output monitoring c) Calorie counts for oral nutrients d) Daily weights e) Strict bedrest

d) Daily weights b) Intake and output monitoring c) Calorie counts for oral nutrients Explanation: For the patient receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the patient is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the patient's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the patient's ability to maintain muscle tone. Strict bedrest is not appropriate. pg.1233

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following? a) Nasogastric tube b) Jejunostomy tube c) Orogastric tube d) Gastrostomy tube

d) Gastrostomy tube Explanation: A gastrostomy tube enters the stomach through a surgically created opening into the abdominal wall. A jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall. A nasogastric tube passes through the nose into the stomach via the esophagus. An orogastric tube passes through the mouth into the stomach. pg.1214

A nurse prepares a patient for insertion of a nasoenteric tube. What position should the nurse place the patient in? a) Flat in bed b) On his or her right side c) In semi-Fowler's position with his or her head turned to the left d) In high-Fowler's position

d) In high-Fowler's position Explanation: During insertion, the patient usually sits upright (high-Fowler's position) with a towel or other protective barrier spread in a biblike fashion over the chest. pg.1216

The nurse is caring for a patient who is at receiving continuous enteral tube feedings who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. Which of the following is the correct action by the nurse? a) Lower the head of the bed. b) Flush the feeding tube. c) Increase the feeding rate. d) Monitor the feeding closely.

d) Monitor the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the patient more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the patient's risk for aspiration. pg.1221

A patient is to receive parenteral nutrition. The duration of therapy is planned for 4 weeks. The nurse develops a teaching plan for the patient to prepare for insertion of which of the following as most likely? a) Peripherally inserted central catheter b) Implanted port c) Tunneled central catheter d) Nontunneled central catheter

d) Nontunneled central catheter Explanation: Because therapy will last fewer than 6 weeks, the patient will most likely receive a nontunneled central catheter. Peripherally inserted central catheters are used for intermediate-term (several days to months) therapy sessions, while tunneled catheters and implanted ports are used for long-term therapy. pg.1229

Which of the following is the best noninvasive means of unclogging tubes? a) Cranberry juice b) Cola c) Meat tenderizer d) Pancreatic enzymes and water

d) Pancreatic enzymes and water Explanation: Cola and cranberry juice have historically been recommended as effective, noninvasive means of unclogging tubes. Evidence indicates that a mixture of pancreatic enzymes and water is superior in restoring the patency of feeding tubes. pg.1218

Before inserting a gastric or enteric tube, the nurse determines the length of tubing that will be needed to reach the stomach or small intestine. The Levin tube, a commonly used nasogastric tube, has circular markings at specific points. This tube should be inserted to 6 to 10 cm beyond what length? a) A length of 50 cm (20 in) b) The distance determined by measuring from the tragus of the ear to the xiphoid process c) A point that equals the distance from the nose to the xiphoid process d) The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process

d) The distance measured from the tip of the nose (N) to the earlobe (E) and from the earlobe to the xiphoid (X) process Explanation: Using this measurement, the nose-earlobe-xiphoid process (NEX), will prevent inserting the tube into the lower esophagus. Two other measurements are used and can be reviewed in the chapter. The average measurement for adults is 22 to 26 inches.

Which of the following is the gold standard for assessing placement of a nasogastric (NG) tube for the patient receiving feedings? a) Use of capnographic device b) pH testing c) Visual assessment of aspiration d) X-ray

d) X-ray Explanation: The gold standard for verifying placement of a blindly inserted tube is radiographic or X-ray confirmation. X-ray confirmation is necessary if the patient will be receiving feedings or medications through the tube. When the tube is used to remove air or fluid and not for instillation, the nurse can use a combination of visually assessing the aspirate, testing its pH, and using capnographic devices to initially determine placement. pg.1217

The most significant complication related to continuous tube feedings is a disturbance of intestinal and hepatic metabolism. the interruption of GI integrity. an interruption in fat metabolism and lipoprotein synthesis. the increased potential for aspiration.

the increased potential for aspiration.

The most significant complication related to continuous tube feedings is the interruption of GI integrity. an interruption in fat metabolism and lipoprotein synthesis. a disturbance of intestinal and hepatic metabolism. the increased potential for aspiration.

the increased potential for aspiration.

A client who had oral cancer has had extensive surgery to excise the malignancy. Although surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to this client and family? time to mourn, accept, and adjust to the loss knowing that everything will work out just fine not giving in to anger having a courageous attitude

time to mourn, accept, and adjust to the loss

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: A. total gastrectomy. B. bariatric surgery. C. diverticulitis. D. gastroesophageal reflux disease (GERD).

total gastrectomy.

The nurse recognizes which change of the GI system is an age-related change? - increased motility - hypertrophy of the small intestine - weakened gag reflex - increased mucus secretion

- weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

The nurse is reviewing the results of a Hemoccult test with the client. Which question asked by the nurse is important in screening for the potential of a false-positive result. Select all that apply. - "Do you take an iron supplement on a daily basis?" - "Does your diet include a moderate amount of vitamin C?" - "Are you prescribed regular strength aspirin daily?" - "Can you tell me the amount of alcohol that you drink on an average week?" - "When was the last time that you included red meat in your diet?"

- "Are you prescribed regular strength aspirin daily?" - "Can you tell me the amount of alcohol that you drink on an average week?" - "When was the last time that you included red meat in your diet?" Explanation: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make? - "It is a body part that is least examined." - "It is a part of the assessment of every client." - "Your problem is in your mouth and not your abdomen." - "Changes in the mouth can help explain why your condition is occurring."

- "Changes in the mouth can help explain why your condition is occurring." Explanation: A complete assessment of the oral cavity is essential because many disorders, such as cancer, diabetes, and immunosuppressive conditions resulting from medication therapy or acquired immunodeficiency syndrome, may be manifested by changes in the oral cavity, including stomatitis. Assessment of the mouth is not done because it is the body part least examined. It is not assessed because it is a part of every assessment. The nurse has no way of knowing if the client's gastrointestinal problem is in the client's mouth.

A client is scheduled for an ultrasound of the abdomen. Which statement indicates that teaching provided to the client to prepare for the test was effective? - "I will take an over-the-counter enema before the test." - "I will not eat or drink for 8 to 12 hours before the test." - "I will ingest a clear liquid diet for 3 days before the test." - "I will take medications to reduce gastric acid before the test."

- "I will not eat or drink for 8 to 12 hours before the test." Explanation: Ultrasonography is a noninvasive diagnostic technique in which high-frequency sound waves are passed into internal body structures, and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities. It is particularly useful in the detection of an enlarged gallbladder or pancreas, or the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. The client should be instructed to fast for 8 to 12 hours before the test to decrease the amount of gas in the bowel. Enemas are not needed before an abdominal ultrasound. A clear liquid diet is not needed before the test. Medications to reduce gastric acid are not required before the test.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? - "I'll avoid eating or drinking anything 6 to 8 hours before the test." - "I'll drink full liquids the day before the test." - "There is no need for special preparation before the test." - "I'll take a laxative to clear my bowels before the test."

- "I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: - "It tells the physician what type of cancer is present." - "It indicates if a cancer is present." - "It determines functionality of the liver." - "It detects a protein normally found in the blood."

- "It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested? - 1 day - 2 days - 3 days - 4 days

- 3 days Explanation: As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.

Which of the following digestive enzymes aids in the digesting of starch? - Amylase - Lipase - Trypsin - Bile

- Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? - Prepare for a prostate examination. - Ask the client to empty the bladder. - Assist the client to a Fowler's position. - Dim the lights for privacy.

- Ask the client to empty the bladder. Explanation: The physical examination of the gastrointestinal system includes assessment of the mouth, abdomen, and rectum. It requires good light, full exposure of the abdomen, warm hands with short nails, and a relaxed client with an empty bladder. A full bladder will interfere with inspection and may elicit discomfort with palpation and percussion, thereby altering results.

An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia? - Atrophy of the gastric mucosa - Decrease in intestinal flora - Increase in bile secretion - Dulling of nerve impulses

- Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? - Avoid smoking for at least 12 to 24 hours before the procedure. - Take vitamin K before the procedure. - Take three cleansing enemas before the procedure. - Avoid the intake of red meat before the procedure.

- Avoid smoking for at least 12 to 24 hours before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.

Which of the following is the most definitive means of assessing for liver disease? - Biopsy - Paracentesis - Cholecystography - Ultrasonography

- Biopsy Explanation: Liver biopsy is the most effective means of diagnosing liver disease. Guided liver biopsy can be conducted using laparoscopy, the insertion of a fiberoptic endoscope through a small abdominal incision. Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Cholecystography and ultrasonography may be used to detect gallstones. Ultrasonography may also be used to visualize the liver and diagnose conditions such as liver fibrosis; noninvasive techniques such as this can reduce the need for liver biopsy.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? - Dark brown - Green - Red - Black

- Black Explanation: Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

A client reports a history of bleeding hemorrhoids to the nurse. Which observation supports the client's statement? - Hard, dry stool - Dark red stool - Black tarry stool - Blood streaks on stool

- Blood streaks on stool Explanation: Blood in the stool can present in various ways and must be investigated. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue. Hard, dry stool occurs in constipation. If blood is shed in sufficient quantities into the upper GI tract, it produces a dark red color, a tarry-black color, or melena.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? - Small bowel series - Computer tomography - Colonoscopy - Upper GI series

- Colonoscopy Explanation: A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

The nurse is scheduling a client for a gastrointestinal motility study. The nurse knows that this type of diagnostic test will aid in determine which of the following alterations? - Esophageal varices - Dumping syndrome - Diabetic gastroparesis - Duodenal disease - Disorders of gastric motility

- Dumping syndrome - Diabetic gastroparesis - Disorders of gastric motility Explanation: Radionuclide testing is used to assess gastric emptying and colonic transit time. During gastric emptying studies, the liquid and solid components of a meal are tagged with radionuclide markers. After ingestion of the meal, the client is positioned under a scintiscanner, which measures the rate of passage of the radioactive substance from the stomach. This is useful in diagnosing disorders of gastric motility, diabetic gastroparesis, and dumping syndrome. A gastrointestinal motility study is not used to diagnose esophageal varices or a duodenal disease. Duodenal disease is diagnosed using fibroscopy.

A client is having a colonic transit study to diagnose a gastrointestinal disorder. Which instruction will the nurse provide to the client after taking a capsule containing radionuclide markers? - Follow a regular diet and usual daily activities. - Ingest a clear liquid diet and take over-the-counter laxatives. - Maintain nothing by mouth status and take oral medications. - Eat a low-fat diet and take proton pump inhibitor medication.

- Follow a regular diet and usual daily activities. Explanation: Colonic transit studies are used to evaluate colonic motility and obstructive defecation syndromes. The client is given a capsule containing 20 radionuclide markers and instructed to follow a regular diet and usual daily activities. There is no reason for the client to follow a clear liquid diet, take over-the-counter laxatives, maintain nothing by mouth status, take oral medications, eat a low-fat diet, or take proton pump inhibitor medications.

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first? - Further investigate the initial complaint. - Explain that fatty foods can mimic chest pain. - Call for an immediate electrocardiogram. - Administer an over-the-counter antacid tablet.

- Further investigate the initial complaint. Explanation: While fatty foods can cause discomfort similar to chest pain, the nurse must fully assess all the client's symptoms. Investigation of chief complaint begins with a complete history. The underlying cause of pain influences the characteristics, duration, pattern, location, and distribution of pain.

A client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test? - History of allergies - Presence of a cochlear implant - Last use of an oral laxative - Current list of prescribed medications

- History of allergies Explanation: A CT scan provides cross-sectional images of abdominal organs and structures. A CT scan may be performed with or without oral or intravenous (IV) contrast, but the enhancement of the study is greater with the use of a contrast agent. A common risk from IV contrast agents is allergic reactions; therefore, the client must be screened for this risk. Any allergies to contrast agents, iodine, or shellfish must be determined before administration of a contrast agent. Clients allergic to the contrast agent may be premedicated with a corticosteroid and antihistamine. Therefore, a history of allergies must be completed before the test. Assessing for the presence of a cochlear implant is recommended before magnetic resonance imaging (MRI), but not before a CT scan. The last use of an oral laxative and current list of prescribed medications are not required before a CT scan of the abdomen.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? - Normal - Hypoactive - Hyperactive - Borborygmi

- Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).

Gastrin has which of the following effects on gastrointestinal (GI) motility? - Increased motility of the stomach - Relaxation of the colon - Contraction of the ileocecal sphincter - Relaxation of gastroesophageal sphincter

- Increased motility of the stomach Explanation: Gastrin has the following effects on GI motility: increased motility of the stomach, excitation of the colon, relaxation of ileocecal sphincter, and contraction of the gastroesophageal sphincter.

A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test? - Ingest nothing by mouth after midnight. - Eat a clear liquid breakfast before the test. - Withhold oral medications for 24 hours before the test. - Avoid products containing aspirin for a week before the test.

- Ingest nothing by mouth after midnight. Explanation: An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent such as barium. To prepare for the test, the client should be instructed to ingest nothing after midnight before the test. Clear liquids are not permitted the morning of the test. Most oral medications are withheld the morning of the test, but not for 24 hours before. There is no reason to avoid products containing aspirin for a week before the test.

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings? - Listen longer for the sounds. - Document that the client is constipated. - Call the health care provider to report absent bowel sounds. - Return in 1 hour and listen again to confirm findings.

- Listen longer for the sounds. Explanation: Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.

What part of the GI tract begins the digestion of food? - Mouth - Duodenum - Esophagus - Stomach

- Mouth Explanation: Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? - Gallbladder - Pancreas - Stomach - Liver

- Pancreas Explanation: The pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions? - Pentagastrin - Atropine - Glycopyrronium bromide - Acetylcysteine

- Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.

Which of the following is an enzyme secreted by the gastric mucosa? - Pepsin - Trypsin - Ptyalin - Bile

- Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? - Instruct the client to have low-residue meals. - Allow the client to ingest fat-free meal. - Permit the client to drink only clear liquids. - Provide saline gargles to the client.

- Permit the client to drink only clear liquids. Explanation: After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.

An examiner is performing the physical assessment of the rectum, perianal region, and anus. While this examination can be uncomfortable for many clients, health care providers must approach it in a prepared, confident manner. Which of the following considerations will help this examination flow smoothly and efficiently for both provider and client? Select all that apply. - Position the client on the right side with the knees up to the chest. - Ask the client to bear down for visual inspection. - Cleanse gloved fingers with water to allow for easy insertion. - Dim the lights to decrease the client's embarrassment. - Ask the client to produce a bowel movement after the procedure.

- Position the client on the right side with the knees up to the chest. - Ask the client to bear down for visual inspection. Explanation: While examination of the rectum, perineum, and anus may be uncomfortable for the client, it is necessary for a thorough examination. The examiner will position the client on the right side with the knees up. He or she will use a gloved finger lubricated with a water-soluble lubricant for ease of insertion. The health care provider will encourage deep breathing during the procedure and ask the client to bear down while inspecting the anal area. The examination requires appropriate lighting for thorough inspection.

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances? - Positron emission tomography (PET) - Computed tomography (CT) - Magnetic resonance imaging (MRI) - Fibroscopy

- Positron emission tomography (PET) Explanation: PET produces images of the body by detecting the radiation emitted from radioactive substances. CT provides cross-sectional images of abdominal organs and structures. MRI uses magnetic fields and radio waves to produce an image of the area being studied. Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted endoscope.

A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage? Greater than 160 mL Between 120 and 160 mL Approximately 80 to 120 mL Between 40 and 80 mL

Approximately 80 to 120 mL

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? - Complete blood count (CBC) - Prothrombin time (PT) - Blood chemistry - Erythrocyte sedimentation rate (ESR)

- Prothrombin time (PT) Explanation: The client must have coagulation studies (PT, aPTT, INR, platelet count) before the procedure because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum? - Cardiac sphincter - Hypopharyngeal sphincter - Ileocecal valve - Pyloric sphincter

- Pyloric sphincter Explanation: The pyloric sphincter is the opening between the stomach and duodenum. The cardiac sphincter is the opening between the esophagus and the stomach. The hypopharyngeal sphincter or upper esophageal sphincter prevents food or fluids from re-entering the pharynx. The ileocecal valve is located at the distal end of the small intestine and regulates flow of intestinal contents into the large intestine.

The nurse determines a client scheduled to undergo an abdominal ultrasonography should receive which instruction? - Do not undertake any strenuous exercise for 24 hours before the test. - Do not consume anything sweet for 24 hours before the test. - Avoid exposure to sunlight for at least 6 to 8 hours before the test. - Restrict eating of solid food for 6 to 8 hours before the test.

- Restrict eating of solid food for 6 to 8 hours before the test. Explanation: A client scheduled to undergo an abdominal ultrasonography should restrict eating of all solid food for 6 to 8 hours to avoid having images of the test obscured with gas and intestinal contents. Ultrasonography records the reflection of sound waves. Strenuous exercises, the consumption of sweets, and exposure to sunlight do not affect the results of the test in any way.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? - A complete blood count including differential - Serum antibodies for H. pylori - A sigmoidoscopy - Gastric analysis

- Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.

The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected? - Liver - Ileum - Stomach - Large Intestine

- Stomach Explanation: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? - Supine with knees flexed - Knee-chest - Lithotomy - Left Sim's lateral

- Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

While preparing a client for an upper GI endoscopy (esophagogastroduodenoscopy), the nurse should implement which interventions? Choose all that apply. - Administer a preparation to cleanse the GI tract, such as Golytely or Fleets Phospha-Soda. - Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. - Tell the client he must be on a clear liquid diet for 24 hours before the procedure. - Inform the client that he will receive a sedative before the procedure. - Tell the client that he may eat and drink immediately after the procedure.

- Tell the client he shouldn't eat or drink for 6 to 12 hours before the procedure. - Inform the client that he will receive a sedative before the procedure. Explanation: The client should be NPO for 8 hours prior to the examination. Before the introduction of the endoscope, the client is given a local anesthetic gargle or spray. Midazolam (Versed), a sedative that provides moderate sedation and relieves anxiety during the procedure, may be administered. Atropine may be administered to reduce secretions, and glucagon may be administered to relax smooth muscle.

What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)? - The client has hemorrhoidal bleeding - The client had a hamburger for dinner the night before - The client took an ibuprofen tablet this morning - The client regularly takes aspirin

- The client has hemorrhoidal bleeding Explanation: FOBT should not be performed when there is hemorrhoidal bleeding. In the past, clients were taught to avoid aspirin, red meats, nonsteroidal anti-inflammatory agents, and horseradish for 72 hours prior to the examination. However, these restrictions are no longer advised as the actual effects on testing have not been established.

Which nursing instruction is correct to provide the client following a barium enema? - The client will maintain a low residue diet. - The stools may be a white or clay colored. - Sips of fluid may be increased if tolerated. - An enema will be used to clear the bowel.

- The stools may be a white or clay colored. Explanation: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? - Both tests need to be done before breakfast. - The ultrasonography should be scheduled before the GI procedure. - The upper GI should be scheduled before the ultrasonography. - The client may eat a light meal before either test.

- The ultrasonography should be scheduled before the GI procedure. Explanation: Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure? - The client is probably hypoglycemic and requires the glucagon. - To relieve anxiety during the procedure for moderate sedation. - To reduce air accumulation in the colon. - To relax colonic musculature and reduce spasm.

- To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.

When describing the role of the pancreas to a client with a pancreatic dysfunction, the nurse would identify which substance as being acted on by pancreatic lipase? - Starch - Protein - Triglycerides - Glucose

- Triglycerides Explanation: Pancreatic lipase acts on lipids, especially triglycerides. Salivary amylase and pancreatic amylase act on starch. Pepsin and hydrochloric acid in the stomach and trypsin from the pancreas act on proteins. Insulin acts on glucose.

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? - chronic atrophic gastritis - duodenal ulcer - gastric cancer - pernicious anemia

- duodenal ulcer Explanation: Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system? - duodenum - jejunum - ileum - cecum

- duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

The major carbohydrate that tissue cells use as fuel is - chyme. - proteins. - glucose. - fats.

- glucose. Explanation: Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.

Which response is a parasympathetic response in the GI tract? - decreased gastric secretion - blood vessel constriction - increased peristalsis - decreased motility

- increased peristalsis Explanation: Increased peristalsis is a parasympathetic response in the GI tract. Decreased gastric secretion, blood vessel constriction, and decreased motility are sympathetic responses in the GI tract.

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition? - inflammatory bowel disease - chronic obstructive pulmonary disease - congestive heart failure - pulmonary hypertension

- inflammatory bowel disease Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.

The nurse performs an abdominal assessment. The nurse should perform the assessment in which order? - inspection, palpation, percussion, auscultation - inspection, auscultation, percussion, palpation - auscultation, percussion, inspection, palpation - auscultation, inspection, percussion, palpitation

- inspection, auscultation, percussion, palpation Explanation: The correct order for the abdominal assessment is inspection, auscultation, percussion, and palpation.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are - normal. - hypoactive. - sluggish. - absent.

- normal. Explanation: Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for - recent foods ingested. - occult blood. - ingestion of bismuth. - pilonidal cyst.

- recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.

Which procedure is performed to examine and visualize the lumen of the small bowel? - small bowel enteroscopy - colonoscopy - panendoscopy - peritoneoscopy

- small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

The nurse is preparing to assess the abdomen of a client experiencing a gastrointestinal condition. Place in order the actions the nurse will take to complete this assessment. Use all options. 1 Position supine. 2 Flex the knees. 3 Inspect the skin. 4 Auscultate bowel sounds. 5 Percuss abdominal organs. 6 Palpate for tenderness and masses.

1 Position supine. 2 Flex the knees. 3 Inspect the skin. 4 Auscultate bowel sounds. 5 Percuss abdominal organs. 6 Palpate for tenderness and masses.

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120 Explanation: The patient receives 30 mL every 6 hours. So over a 24-hour period, the patient would receive 4 irrigations. 4 times 30 mL equals 120 mL. pg.1215

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 Explanation: Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance. pg.1219

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280 Explanation: The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL. pg.1232

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? 4 6 1 2

6

A client had a central line inserted for parenteral nutrition and is awaiting transport to the radiology department for catheter placement verification. The client reports feeling anxious and has a respiratory rate of 28 breaths/minute. What is the next action of the nurse? A) Auscultate lung sounds B) Position client flat in bed C) Apply nasal cannula oxygen D) Consult with the healthcare provider

A

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? A) Gastroesophageal reflux disease B) Gastritis C) Peptic ulcer with melena D) Diverticulitis with perforation

A

A client's new onset of dysphagia has required insertion of an NG tube for feeding. What intervention should the nurse include in the client's plan of care? A) Confirm placement of the tube prior to each scheduled feeding. B) Connect the tube to continuous wall suction when not in use. C) Keep the client in a low Fowler position when at rest. D) Have the client sip cool water to stimulate saliva production.

A

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is A) Inserted into the lungs B) Irritating the epiglottis C) Coiling in the client's mouth D) Passing into the esophagus

A

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? A) "Avoid coffee and alcoholic beverages." B) "Lie down after meals to promote digestion." C) "Limit fluid intake with meals." D) "Take antacids with meals."

A

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? A) Weakness, diaphoresis, diarrhea 90 minutes after eating B) Constipation, rectal bleeding following bowel movements C) Persistent loose stools, chills, hiccups after eating D) Abdominal distention, elevated temperature, weakness before eating

A

While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit? Between 40 and 80 mL Between 120 and 160 mL Greater than 160 mL Approximately 80 to 120 mL

Approximately 80 to 120 mL

A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem? A. A GI malignancy B. Dumping syndrome C. Peptic ulcer disease D. Esophageal/gastric obstruction

A GI malignancy

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). Which statement(s) by the client indicates effective knowledge of the procedure? Select all that apply. A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." B. "It is likely that I will need to receive nutrition directly into my veins." C. "One of my nerves, the vagus nerve, may be cut during the surgery." D. "I can eat a normal diet again after 3 to 5 weeks." E. "This surgery will remove part of my stomach and colon."

A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." C. "One of my nerves, the vagus nerve, may be cut during the surgery."

A patient comes to the bariatric clinic to obtain information about bariatric surgery. The nurse assesses the obese patient knowing that in addition to meeting the criterion of morbid obesity, a candidate for bariatric surgery must also demonstrate what? A) Knowledge of the causes of obesity and its associated risks B) Adequate understanding of required lifestyle changes C) Positive body image and high self-esteem D) Insight into why past weight loss efforts failed

Adequate understanding of required lifestyle changes

A client who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the client is alert. What is the client's priority need at this time? Emotional support from visitors and staff Referral to a speech therapist Dietary teaching focused on consistency of food and frequency of feedings An effective means of communicating with the nurse

An effective means of communicating with the nurse

A patient has been diagnosed with peptic ulcer disease and the nurse is reviewing his prescribed medication regimen with him. What is currently the most commonly used drug regimen for peptic ulcers? A) Bismuth salts, antivirals, and histamine-2 (H2) antagonists B) H2 antagonists, antibiotics, and bicarbonate salts C) Bicarbonate salts, antibiotics, and ZES D) Antibiotics, proton pump inhibitors, and bismuth salts

Antibiotics, proton pump inhibitors, and bismuth salts

A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first? Notify the surgeon to repair the vessel Summon assistance Elevate the head of the patient's bed Apply pressure to the bleeding site

Apply pressure to the bleeding site

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? Assess the graft for color and temperature. Reinforce the neck dressing when blood is present on the dressing. Administer prescribed intravenous vancomycin at the correct time. Cleanse around the drain using aseptic technique.

Assess the graft for color and temperature.

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client? Reinforce the neck dressing when blood is present on the dressing. Cleanse around the drain using aseptic technique. Assess the graft for color and temperature. Administer prescribed intravenous vancomycin at the correct time.

Assess the graft for color and temperature.

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

Avoid drinking alcohol while taking the drug.

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

Avoiding taking aspirin to treat pain or fever

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? A) Administer 15 to 30 mL of water before and after medications and feedings. B) Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. C) Avoid cessation of feedings and adjust patient head of bed. D) Change the tube feeding container , tubing , and adjust patient head of bed.

B

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? A) Small bowel obstruction B) Dumping syndrome C) Diverticulosis D) Paralytic ileus

B

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse? A) Document the discontinuation of the nasogastric tube. B) Notify the surgeon about the tube's removal. C) Reinsert the nasogastric tube to the stomach. D) Place the nasogastric tube to the level of the esophagus.

B

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? A) manifestations of hypoglycemia. B) diaphoresis, vomiting, and diarrhea. C) manifestations of electrolyte disturbances. D) constipation, dehydration, and hypercapnia.

B

A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action? A) Apply topical anesthetic to the client's nares as prescribed. B) Explain the process clearly to the client. C) Assess the client's appetite. D) Assist the client into a supine position.

B

A nurse is admitting a client to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? A) Development of peptic ulcer disease (PUD) B) Premature removal of the G tube C) Constipation D) Bowel perforation

B

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? A) "It works as a marker to make sure that the tube stays in place." B) "It is a vent that prevents backflow of the secretions." C) "It helps regulate the pressure on the suction machine." D) "It acts as a siphon, pulling secretions into the clear tubing."

B

A patient is receiving continuous tube feedings. The nurse would maintain the patient in which position at all times? A) Supine with a small pillow under the patient's head B) Semi-Fowler's with the head of the bed elevated 30 to 45 degrees C) High Fowler's with the patient sitting erect D) Side-lying with the head slightly lower than the chest

B

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery? A) Vestibulocochlear B) Vagus C) Trigeminal D) Hypoglossal

B

The nurse is caring for a patient who has dumping syndrome from high-carbohydrate foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? A) Administer the feeding by bolus to prevent continuous intestinal distention. B) Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. C) Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. D) Administer the feeding at a warm temperature to decrease peristalsis.

B

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of A) roasted nuts. B) organic fruit juice. C) cheddar cheese. D) red meat that is high in fat.

B

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? A) Notify the physician. B) Remove the dressing, clean the site, and apply a new dressing. C) Draw a circle around the moist spot and note the date and time. D) Remove the catheter, check for catheter integrity, and send the tip for culture. SUBMIT ANSWER

B

A nurse is providing care for a patient who is postoperative day 2 following gastric surgery. The nurses assessment should be planned in light of the possibility of what potential complications? Select all that apply. A) Malignant hyperthermia B) Atelectasis C) Pneumonia D) Metabolic imbalances E) Chronic gastritis

B) Atelectasis C) Pneumonia D) Metabolic imbalances

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply. A) Marital status B) Family support C) Motivation for learning D) Telephone access E) Health status

B, C, D, and E

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. A) Decreased bowel sounds B) Diarrhea C) Tachycardia D) Hypertension E) Diaphoresis

B, C, and E

Which clinical manifestation is not associated with hemorrhage? Hypotension Tachypnea Tachycardia Bradycardia

Bradycardia

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? Use a hard-bristled toothbrush. Rinse with an alcohol-based solution. Brush and floss daily. Continue with the usual diet.

Brush and floss daily.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client? A) Anxiety or irritability B) Hyperactivity C) Uncontrolled rhythmic movements of the face or limbs D) Dry mouth not relieved by sugar-free hard candy

C

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? A) Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. B) Administer antibiotics via the tube as prescribed. C) Wash the area around the tube with soap and water daily. D) Irrigate the skin surrounding the insertion site with normal saline before each use.

C

A client is receiving parenteral nutrition (PN) through a peripherally inserted central catheter (PICC) and will be discharged home with PN. The home health nurse evaluates the home setting and would make a recommendation when noticing which circumstance? A) Little food in the working refrigerator B) Electricity that loses power, usually for short duration, during storms C) No land line; cell phone available and taken by family member during working hours D) Water of low pressure that can be obtained through all faucets

C

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to A) Change the nasal tape every 2 to 3 days. B) Apply water-based lubricant to the nares daily. C) Auscultate lung sounds every 4 hours. D) Inspect the nose daily for skin irritation.

C

A nurse is providing care for a client with a diagnosis of late-stage Alzheimer disease. The client has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? A) Vigilant monitoring of the frequency and character of bowel movements B) Frequent assessment of the client's abdominal girth C) Frequent lung auscultation D) Assessment for hemorrhage from the nasal insertion site

C

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate? A) Diverticulitis B) Peptic ulcer disease C) Gastroesophageal reflux disease D) Esophageal cancer

C

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? A) 8 p.m. to 10 p.m. B) 4 p.m. to 6 p.m. C) 6 p.m. to 8 p.m. D) 10 p.m. to 12 a.m.

C

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? A) Slow the current infusion rate so that it will last until the new solution arrives. B) Have someone go to the pharmacy to obtain the new solution. C) Hang a solution of dextrose 10% and water until the new solution is available. D) Begin an infusion of normal saline in another site to maintain hydration.

C

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was: A) About 50 mL. B) Between 50 and 80 mL. C) Greater than 200 mL. D) About 100 mL.

C

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? A) 4 B) 2 C) 6 D) 1

C

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? A) Discontinue the infusion. B) Remove the aspirated fluid and do not reinstill. C) Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. D) Dilute the gastric tube feeding solution with water and continue the feeding.

C

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? A) Have the patient eat a cracker as the tube is being inserted. B) Spray the oropharynx with an anesthetic spray. C) Allow the patient to sip water as the tube is being inserted. D) Have the patient maintain a backward tilt head position.

C

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? A) Tape the tube to the head of the bed to avoid dislodgement. B) Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. C) Keep the vent lumen above the patient's waist to prevent gastric content reflux. D) Irrigate only through the vent lumen.

C

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What is the main purpose of these nursing actions? A) Prevent gastric ulcers B) Prevent abdominal distention C) Prevent aspiration D) Prevent diarrhea

C

The primary source of microorganisms for catheter-related infections are the skin and which of the following? A) Catheter tubing B) IV tubing C) Catheter hub D) IV fluid bag

C

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of A) roasted nuts. B) red meat that is high in fat. C) organic fruit juice. D) cheddar cheese.

C

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? A) Administering 15 to 30 mL of water every 4 hours. B) Giving the feedings at room temperature. C) Keeping the client in a semi-Fowler's position at all times. D) Aspirating for residual contents every 4 to 8 hours.

C

Which clinical manifestation is not associated with hemorrhage? A) Tachycardia B) Tachypnea C) Bradycardia D) Hypotension

C

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. A) Daily transparent dressing changes B) Strict bedrest C) Calorie counts for oral nutrients D) Intake and output monitoring E) Daily weights

C, D, and E

The primary source of microorganisms for catheter-related infections are the skin and which of the following? IV fluid bag Catheter tubing IV tubing Catheter hub

Catheter hub

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Diverticulitis with perforation Peptic ulcer with melena Gastritis Gastroesophageal reflux disease

Gastroesophageal reflux disease

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Peptic ulcer with melena Diverticulitis with perforation Gastritis Gastroesophageal reflux disease

Gastroesophageal reflux disease

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct? A) If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. B) Use clean technique when accessing the port with a needle. C) If unsuccessful with the first attempt to access the catheter, reuse the needle and try again. D) Clean the port with an alcohol pad before administering I.V. fluid through the catheter.

D

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following is no longer considered appropriate to use to unclog the tube? A) Digestive enzyme mixed with warm water B) Commercial enzyme product C) Air insufflation D) Cranberry juice

D

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): A) Extension of the esophagus through an opening in the diaphragm. B) Involution of the esophagus, which causes a severe stricture. C) Twisting of the duodenum through an opening in the diaphragm. D) Protrusion of the upper stomach into the lower portion of the thorax.

D

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: A) Feedings can be administered with the patient in the recumbent position. B) The patient cannot experience the deprivational stress of not swallowing. C) Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. D) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

D

The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? A) Polyps removed during a colonoscopy B) History of diverticulitis C) Treatment for internal hemorrhoids D) Diagnosed with malabsorption syndrome

D

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? A) Regurgitation of food B) Pain C) Malnutrition D) Dysphagia

D

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? A) Provide oral hygiene. B) Remove the tape from the nose of the client. C) Withdraw the tube gently for 6 to 8 inches. D) Flush with 10 mL of water.

D

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? A) Have the client lay on the left side. B) Assist the client to drink 8 ounces of water. C) Instruct the client to swallow several times. D) Administer prescribed metoclopramide.

D

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? A) Giving the feedings at room temperature. B) Aspirating for residual contents every 4 to 8 hours. C) Administering 15 to 30 mL of water every 4 hours. D) Keeping the client in a semi-Fowler's position at all times.

D

A nurse is inserting a nasogastric tube for feeding a client. Place in order the steps from 1 to 6 for correctly inserting the tube. A) Apply water-soluble lubricant to the tip of the tube B) Instruct the client to lower the head and swallow C) Tilt the client's nose upward D) Sit the client in an upright position E) Measure the length of the tube that will be inserted F) Apply gloves to the nurse's hands

D, F, E, A, C, and B

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Feedings can be administered with the patient in the recumbent position. Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration.

A patient who is obese is exploring bariatric surgery options and presented to a bariatric clinic for preliminary investigation. The nurse interviews the patient, analyzing and documenting the data. Which of the following nursing diagnoses may be a contraindication for bariatric surgery? A) Disturbed Body Image Related to Obesity B) Deficient Knowledge Related to Risks and Expectations of Surgery C) Anxiety Related to Surgery D) Chronic Low Self-Esteem Related to Obesity

Deficient Knowledge Related to Risks and Expectations of Surgery

A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching

Diarrhea and feelings of fullness

A client with gastric cancer has been scheduled for a total gastrectomy. During the preoperative assessment, the client confides in the nurse feeling the surgery will "mutilate" the client's body. The nurse should plan interventions that address what nursing diagnosis? A. Disturbed body image B. Deficient knowledge related to the risks of surgery C. Anxiety about the surgery D. Low self-esteem

Disturbed body image

A patient comes to the clinic complaining of pain in the epigastric region. What assessment question during the health interview would most help the nurse determine if the patient has a peptic ulcer? A) Does your pain resolve when you have something to eat? B) Do over-the-counter pain medications help your pain? C) Does your pain get worse if you get up and do some exercise? D) Do you find that your pain is worse when you need to have a bowel movement?

Does your pain resolve when you have something to eat?

A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinence B. Drug-drug interactions C. Abdominal pain D. Heat intolerance

Drug-drug interactions

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? Diverticulosis Paralytic ileus Small bowel obstruction Dumping syndrome

Dumping syndrome

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? Small bowel obstruction Dumping syndrome Paralytic ileus Diverticulosis

Dumping syndrome

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? Malnutrition Pain Regurgitation of food Dysphagia

Dysphagia

A nurse caring for a patient who has had bariatric surgery is developing a teaching plan in anticipation of the patients discharge. Which of the following is essential to include? A) Drink a minimum of 12 ounces of fluid with each meal. B) Eat several small meals daily spaced at equal intervals. C) Choose foods that are high in simple carbohydrates. D) Sit upright when eating and for 30 minutes afterward.

Eat several small meals daily spaced at equal intervals

A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines? A) Eat small, frequent meals with high calorie and vitamin content. B) Eat frequent meals with an equal balance of fat, carbohydrates, and protein. C) Eat frequent, low-fat meals with high protein content. D) Try to maintain the pre-diagnosis pattern of eating.

Eat small, frequent meals with high calorie and vitamin content.

A patient is one month postoperative following restrictive bariatric surgery. The patient tells the clinic nurse that he has been having trouble swallowing for the past few days. What recommendation should the nurse make? A) Eating more slowly and chewing food more thoroughly B) Taking an OTC antacid or drinking a glass of milk prior to each meal C) Chewing gum to cause relaxation of the lower esophageal sphincter D) Drinking at least 12 ounces of liquid with each meal

Eating more slowly and chewing food more thoroughly

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Ensure availability of an infusion pump Administer the intravenous antibiotic in the same tubing as the parenteral nutrition Assess for patency of the peripheral intravenous site Place a 1.5-micron filter on the tubing

Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing

A client has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. What is the nurse's best response to this change in health status? Arrange for a diet that is high in protein and low in fat. Ensure that none of the client's visitors have an infection. Prepare to administer chemotherapeutics as prescribed. Administer colony stimulating factors (CSFs) as prescribed.

Ensure that none of the client's visitors have an infection.

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

Esophageal or pyloric obstruction related to scarring

An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom? Gastritis Esophageal tumor Hiatal hernia Gastroesophageal reflux disease

Esophageal tumor

A nurse is performing the admission assessment of a patient whose high body mass index (BMI) corresponds to class III obesity. In order to ensure empathic and patient-centered care, the nurse should do which of the following? A) Examine ones own attitudes towards obesity in general and the patient in particular. B) Dialogue with the patient about the lifestyle and psychosocial factors that resulted in obesity. C) Describe ones own struggles with weight gain and weight loss to the patient. D) Elicit the patients short-term and long-term goals for weight loss.

Examine ones own attitudes towards obesity in general and the patient in particular.

A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine.

Facilitate the client's contact with support services.

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding: Renal studies Fasting blood glucose level Liver function tests Physical assessment data

Fasting blood glucose level

A patient has been prescribed orlistat (Xenical) for the treatment of obesity. When providing relevant health education for this patient, the nurse should ensure the patient is aware of what potential adverse effect of treatment? A) Bowel incontinence B) Flatus with oily discharge C) Abdominal pain D) Heat intolerance

Flatus with oily discharge

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Flush with 10 mL of water. Withdraw the tube gently for 6 to 8 inches. Remove the tape from the nose of the client. Provide oral hygiene.

Flush with 10 mL of water.

A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying? A) Fowlers B) Supine C) Left lateral D) Left Sims

Fowlers

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel. B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection. D. The H. pylori microorganism is endemic in warm, moist climates.

Infection typically occurs due to ingestion of contaminated food and water.

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

Infection with Helicobacter pylori

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and C C. Reflux of bile into the distal esophagus D. Influx of extracellular fluid into the small intestine

Influx of extracellular fluid into the small intestine

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention? Remove the plaque from the mouth by rubbing with gauze. Provide saline rinses prior to meals. Instruct the client to swish prescribed nystatin solution for 1 minute. Encourage the client to ingest a soft or bland diet.

Instruct the client to swish prescribed nystatin solution for 1 minute.

A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care? A. Hematemesis and persistent sensation of fullness B. Abdominal bloating and recurrent constipation C. Intermittent pain and bloody stool D. Unexplained bowel incontinence and fatty stools

Intermittent pain and bloody stool

A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care? A) Hematemesis and persistent sensation of fullness B) Abdominal bloating and recurrent constipation C) Intermittent pain and bloody stool D) Unexplained bowel incontinence and fatty stools

Intermittent pain and bloody stool

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

It protects the stomach's lining

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? Irrigate only through the vent lumen. Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. Tape the tube to the head of the bed to avoid dislodgement. Keep the vent lumen above the patient's waist to prevent gastric content reflux.

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone? Lithotripsy Radiation Biopsy Chemotherapy

Lithotripsy

Which of the following are functions of saliva? Select all that apply. Protection against harmful bacteria Elimination Lubrication Digestion Metabolism

Lubrication Protection against harmful bacteria Digestion

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: Make a notation on the call light system that the client cannot speak. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. Encourage the client to position himself on his side. Provide oxygen without humidity through the tracheostomy tube.

Make a notation on the call light system that the client cannot speak.

A patient who is obese has been unable to lose weight successfully using lifestyle modifications and has mentioned the possibility of using weight-loss medications. What should the nurse teach the patient about pharmacologic interventions for the treatment of obesity? A) Weight loss drugs have many side effects, and most doctors think they'll all be off the market in a few years. B) There used to be a lot of hope that medications would help people lose weight, but its been shown to be mostly a placebo effect. C) Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone. D) Medications are rapidly become the preferred method of weight loss in people for whom diet and exercise have not worked.

Medications can be helpful, but few people achieve and maintain their desired weight loss with medications alone.

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.

Monitor the client closely for further signs of dumping syndrome.

A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube) B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distension D. Monthly administration of injections of vitamin B12

Monthly administration of injections of vitamin B12

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.

Notify the health care provider.

The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate? Notify the physician Lower the head of the bed Administer a breathing treatment Document the presence of stridor

Notify the physician

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? Submandibular Buccal Parotid Sublingual

Parotid

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

Peritonitis

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

Providing the client with physical and emotional support

When a central venous catheter dressing becomes moist or loose, what should a nurse do first? Remove the dressing, clean the site, and apply a new dressing. Draw a circle around the moist spot and note the date and time. Remove the catheter, check for catheter integrity, and send the tip for culture. Notify the physician.

Remove the dressing, clean the site, and apply a new dressing.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

Tachycardia, hypotension, and tachypnea

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

The client has a rigid, "board-like" abdomen that is tender.

A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. Which of the following actions is most likely to accomplish this? A. The nurse gauges the client's response to hypothetical outcomes. B. The client is encouraged to express fears openly. C. The nurse provides detailed and accurate information about the disease. D. The nurse closely observes the client's body language.

The client is encouraged to express fears openly.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to a) Auscultate lung sounds every 4 hours. b) Inspect the nose daily for skin irritation. c) Apply water-based lubricant to the nares daily. d) Change the nasal tape every 2 to 3 days.

a) Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant. pg.1219

The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is a) Auscultate lung sounds. b) Elevate the head of the bed. c) Position client flat in bed. d) Consult with the healthcare provider.

a) Auscultate lung sounds. Explanation: Following placement of a central line, the client is at risk for a pneumothorax. The client's report of anxiety and increased respiratory rate may be the first signs and symptoms of a pneumothorax. The nurst first assesses the client by auscultating lung sounds. Other actions include placing the client in Fowler's position and consulting with the healthcare provider about findings. pg.1231

To ensure patency of central venous line ports, diluted heparin flushes are used in which of the following situations? a) Daily when not in use b) When the line is discontinued c) With continuous infusions d) Before drawing blood

a) Daily when not in use Explanation: Daily instillation of dilute heparin flush when a port is not in use will maintain the port. Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion. Heparin flushes are used after blood drawing in order to prevent clotting of blood within the port. Heparin flush of ports is not necessary if a line is to be discontinued. pg.1231

The nurse is caring for a comatose patient and administering gastrostomy feedings. What does the nurse understand is the reason that gastrostomy feedings are preferred to nasogastric (NG) feedings in the comatose patient? a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. b) The patient cannot experience the deprivational stress of not swallowing. c) Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. d) Feedings can be administered with the patient in the recumbent position.

a) Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely. pg.1224

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) a) Until bowel sound is present b) Until the tube comes out on its own c) Until the patient stops vomiting d) Until peristalsis is resumed e) Until flatus is passed

a) Until bowel sound is present e) Until flatus is passed d) Until peristalsis is resumed Explanation: Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene. pg.1219

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician? a) 200 mL b) 225 mL c) 150 mL d) 175 mL

b) 225 mL Explanation: If a residual volume greater than 200 mL is obtained twice, the nurse would need to notify the physician. A single residual volume of 200 mL or more does not indicate a need to withhold a feeding. Feedings may be continued in patients as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient's physical status. pg.1222

A client is recovering from percutaneous endoscopic gastrostomy (PEG) tube placement. The nurse a) Maintains a gauze dressing over the site for 3 days b) Administers an initial bolus of 50 mL water c) Pushes the stabilizing disk firmly against the skin d) Immediately starts the prescribed tube feeding

b) Administers an initial bolus of 50 mL water Explanation: The first fluid nourishment may consist of water, saline, or 10% dextrose. This may be administered as a bolus of 30 to 60 mL. By the second day, formula feeding may begin. A gauze dressing is applied between the tube insertion site and the gastrostomy tube. The dressing is changed daily or as needed. The nurse gently manipulates the stabilizing disk daily to prevent skin breakdown. pg.1226

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct? a) If the needle becomes contaminated before accessing the port, clean the needle with povidone-iodine solution. b) Clean the port with an alcohol pad before administering I.V. fluid through the catheter. c) If unsuccessful with the first attempt to access the catheter, reuse the needle and try again. d) Use clean technique when accessing the port with a needle.

b) Clean the port with an alcohol pad before administering I.V. fluid through the catheter. Explanation: The nurse should clean the port with an alcohol pad before administering I.V. fluid through the catheter to prevent microorganisms from entering the bloodstream. Using clean technique when accessing the port with a needle, cleaning the needle with a povidone-iodine solution, or reusing a needle would break sterile technique. pg.1232

The nurse is attempting to unclog a patient's feeding tube. Attempts with warm water agitation and milking the tube have been unsuccessful. The nurse uses evidence-based practice principles when she then uses which of the following to unclog the tube? a) Cola mixed with cranberry juice b) Digestive enzymes and sodium bicarbonate c) Alka Seltzer mixed with water d) Meat tenderizer diluted with saline

b) Digestive enzymes and sodium bicarbonate Explanation: The nurse should attempt to unclog the tube with digestive enzymes activated with sodium bicarbonate. Although historically both cranberry juice and cola have sometimes been used to unclog feeding tubes, evidence has shown that their acidic nature worsens the clog by causing precipitation of proteins. Meat tenderize diluted with saline is not applicable. pg.1218

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube? a) Prime the tubing with 20 mL of normal saline. b) Keep the vent lumen above the patient's waist. c) Maintain the patient in a high Fowler's position. d) Have the patient pin the tube to the thigh.

b) Keep the vent lumen above the patient's waist. Explanation: The blue vent lumen should be kept above the patient's stomach to prevent reflux of gastric contents through it; otherwise it acts as a siphon. A one-way antireflux valve seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen. To prevent reflux, you do not prime the tubing, maintain the patient in a high Fowler's position, or have the patient pin the tube to the thigh.

When assisting with the plan of care for a client receiving tube feedings, which of the following would the nurse include to reduce the client's risk for aspiration? a) Aspirating for residual contents every 4 to 8 hours. b) Keeping the client in a semi-Fowler's position at all times. c) Giving the feedings at room temperature. d) Administering 15 to 30 mL of water every 4 hours.

b) Keeping the client in a semi-Fowler's position at all times. Explanation: With continuous tube feedings, the nurse needs to keep the client in a semi-Fowler's position at all times to reduce regurgitation and the risk for aspiration. Aspirating for residual contents helps to ensure adequate nutrition and prevent overfeeding. Administering 15 to 30 mL of water every 4 hours helps to maintain tube patency. Giving the feedings at room temperature reduces the risk for diarrhea. pg.1219

The physician orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, the nurse would select which of the following? a) Miller-Abbott tube b) Levin tube c) Sengsten-Blakemore tube d) Salem sump tube

b) Levin tube Explanation: A Levin tube is a single lumen nasogastric tube. A Salem sump tube is a double lumen nasogastric tube; a Sengsten-Blakemore tube is a triple lumen nasogastric tube. A Miller-Abbott tube is a double lumen nasoenteric tube. pg.1215

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? a) Spray the oropharynx with an anesthetic spray. b) Have the patient maintain a backward tilt head position. c) Allow the patient to sip water as the tube is being inserted. d) Have the patient eat a cracker as the tube is being inserted.

c) Allow the patient to sip water as the tube is being inserted. Explanation: During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated. pg.1216

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding: a) Liver function tests b) Physical assessment data c) Fasting blood glucose level d) Renal studies

c) Fasting blood glucose level Explanation: An adverse reaction to tube feedings is an elevated blood glucose level. The physical assessment data and renal function and liver function studies are normal. pg.1221

A client is receiving continuous tube feedings at 75 mL/hr. The nurse has checked the residual volume 4 hours ago as 250 mL. The nurse now assesses the residual volume as 325 mL. The first action of the nurse is to a) Stop the continuous feeding b) Discard the residual volume c) Notify the physician d) Decrease the rate to 40 mL/hr

c) Notify the physician Explanation: The second residual volume is greater than the first. When excessive residual volume (more than 200 mL) of a nasogastric feeding occurs twice, the nurse notifies the physician. The nurse does not discard the aspirate because the client has partially digested this fluid. After discussing with the physician, the nurse may stop the continuous feeding for some time or decrease the rate of infusion. pg.1222

A patient receiving tube feedings has prescriptions for several drugs. Which of the following drugs would the nurse expect to administer to the patient without any special preparation? Select all that apply. a) Sustained-release antihypertensive b) Enteric-coated aspirin c) Sublingual nitroglycerin d) Liquid stool softener e) Acetaminophen tablet

c) Sublingual nitroglycerin d) Liquid stool softener Explanation: Liquid medications do not require any special preparation for administration via a feeding tube. Buccal or sublingual tablets are administered as prescribed. They are absorbed through the mucosa of the cheek or under the tongue and thus would not be administered through the feeding tube. Enteric-coated aspirin and sustained-release antihypertensive could not be given as is through a feeding tube. A change in formulation would be needed. An acetaminophen tablet would need to be crushed and dissolved in water before being given.

Hickman and Groshong are examples of which type of central venous access device? a) Nontunneled central catheter b) Peripherally inserted central catheters (PICC) c) Tunneled central catheters d) Implanted ports

c) Tunneled central catheters Explanation: Hickman and Groshong catheters are examples of tunneled central catheters. MediPort is an implanted port. A percutaneous subclavian Arrow is an example of a nontunneled central catheter. A PICC line is used for intermediate-term IV therapy for the hospital, long-term care, or the home setting. pg.1230

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 remain alert for: a) constipation, dehydration, and hypercapnia. b) manifestations of electrolyte disturbances. c) diaphoresis, vomiting, and diarrhea. d) manifestations of hypoglycemia.

c) diaphoresis, vomiting, and diarrhea. Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings. pg.1223

After teaching a patient about the procedure for inserting a nontunneled central catheter, the nurse determines that the patient has understood the instructions based on which of the following statements? a) "I need to keep my head turned directly toward you and the physician." b) "I will need to take long, slow, deep breaths when the catheter is inserted." c) "I'll have to wear a thick, bulky dressing over the site." d) "I will be lying on my back but my legs will be higher than my head."

d) "I will be lying on my back but my legs will be higher than my head." Explanation: For catheter insertion, the patient is in the Trendelenburg position to produce dilation of the neck and shoulder vessels, which makes entry easier and decreases the risk of air embolus. The patient is instructed to turn the head away from the site of the venipuncture and to remain motionless while the catheter is inserted and the site is dressed. During insertion, until the syringe is detached from the needle and the catheter is inserted, the patient may be asked to perform the Valsalva maneuver, not take long, slow, deep breaths. Typically a transparent dressing is applied over the insertion site. pg.1229

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse a) Discusses with the nutritionist about increasing the osmolality of the feeding b) Increases the amount of feeding at the next feeding c) Administers the feeding at a cooler temperature d) Consults with the physician about decreasing the feeding to half-strength

d) Consults with the physician about decreasing the feeding to half-strength Explanation: The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution. pg.1220

The nurse is monitoring a patient with nasoenteric intubation. The nurse contacts the physician when which of the following is noted? a) Blood pressure 118/72 b) Moist mucous membranes c) Heart rate of 100 d) Urinary output 20 mL/hr

d) Urinary output 20 mL/hr Explanation: The nurse should notify the physician when the patient has a urinary output of 20 mL/hr as this is a decreased urinary rate. Decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate are signs and symptoms of fluid volume deficit. A heart rate of 100, BP of 118/72, and moist mucous membranes are findings that are within acceptable ranges/limits and do not indicate a fluid volume deficit. pg.1219

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention a) Change the transparent dressing every 3 days. b) Assess the PICC insertion site daily. c) Use clean gloves when providing site care. d) Wear a face mask during dressing changes.

d) Wear a face mask during dressing changes. Explanation: The Centers for Disease Control and Prevention (CDC) recommends changing central vascular access device dressings every 7 days. During dressing changes, the nurse and client wear face masks to reduce the possibility of airborne contamination. The transparent dressing allows for frequent assessments of the site. This is to be done more frequently than daily. During dressing changes, the nurse wears sterile gloves. pg.1229

A patient has just had a nasogastric (NG) tube inserted and the nurse is waiting for verification of placement of the tube prior to starting tube feedings. Which is the best method of verification the nurse should use for determining new NG tube placement? a) Observing gastric aspirate b) Gastric aspirate pH testing c) Air auscultation d) X-ray confirmation

d) X-ray confirmation Explanation: Radiologic identification of tube placement in the stomach is the most reliable method. Gastric fluid may be grassy green, brown, clear, or odorless, whereas an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining NG tube placement in the stomach. Gastric pH values are typically lower or more acidic than that of the intestinal or respiratory tract, but not always. Air auscultation is not a reliable method for determining NG tube placement in the stomach when used alone. pg.1216

The primary source of microorganisms for catheter-related infections are the skin and a) IV fluid bag. b) IV tubing. c) catheter tubing. d) catheter hub.

d) catheter hub. Explanation: The primary sources of microorganisms for catheter-related infections are the skin and the catheter hub. The catheter site is covered with an occlusive gauze dressing that is usually changed every other day. pg.1232

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for? manifestations of hypoglycemia. diaphoresis, vomiting, and diarrhea. manifestations of electrolyte disturbances. constipation, dehydration, and hypercapnia.

diaphoresis, vomiting, and diarrhea.

The client is experiencing swallowing difficulties and is now scheduled to receive a gastric feeding. The client has the following oral medications prescribed: furosemide, digoxin, enteric coated aspirin, and vitamin E. The nurse would withhold which medication? furosemide digoxin vitamin E enteric coated aspirin

enteric coated aspirin

A nurse suspects that a patient is developing rebound hypoglycemia secondary to parenteral nutrition being discontinued too rapidly. Which of the following would support the nurse's suspicions? Select all that apply. a) Weakness b) Confusion c) Dry, hot skin d) Reports of feeling flushed e) Tachycardia f) Shakiness

f) Shakiness e) Tachycardia a) Weakness b) Confusion Explanation: Signs and symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate. pg.1230

The nurse provides health teaching to inform the client with oral cancer that a typical lesion is soft and craterlike. many oral cancers produce no symptoms in the early stages. blood testing is used to diagnose oral cancer. most oral cancers are painful at the outset.

many oral cancers produce no symptoms in the early stages.