Acute 1 Group Projects: Gastrointestinal

The nurse is caring for a patient who reports abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient's condition is declining? A. Pallor and diaphoresis B. Reddened peripheral IV site C. Guaiac-positive diarrhea stools D. Heart rate 90, respiratory rate 20, BP 110/60

ANS: A A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. A reddened peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the IV site does not represent a decline in condition.

A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate preparing the patient for a. endoscopy. b. angiography. c. gastric analysis testing. d. barium contrast studies.

ANS: A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding.

All the following orders are received for a patient who has vomited 1500 mL of bright red blood. Which order will the nurse implement first? a. Insert a nasogastric (NG) tube and connect to suction. b. Administer intravenous (IV) famotidine (Pepcid) 40 mg. c. Draw blood for typing and crossmatching. d. Infuse 1000 mL of lactated Ringer's solution.

ANS: D Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

A patient who is vomiting bright red blood is admitted to the emergency department. Which assessment should the nurse perform first? a. Checking the level of consciousness b. Measuring the quantity of any emesis c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

ANS: D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.

The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a. regular diet b. skim milk c. nothing by mouth d. clear liquids

Answer C: Shock and bleeding must be controlled before oral intake, so the client should receive nothing by mouth. When the bleeding is controlled, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn't be given because it increases gastric acid production, which could prolong bleeding. A liquid diet is the first diet offered after bleeding and shock are controlled.

A nurse identifies that a patients colostomy stoma is pale. what should the nurse do? 1. notify the practitioner 2. listen for bowel sounds 3. wash the area with warm water 4. gently massage around stoma

Answer: 1 Rationale: a pale stoma indicates that the circulation to the stomal is compromised and viability of tissue is questionable without immediate intervention. Listening for bowel sounds might be done but is not priority. Washing with warm water is inappropriate and a waste of time and massaging may injure surrounding tissue.

A patient is experiencing constipation. Which independent nursing action facilitates defecation of hard stool? 1. applying lubricant to the anus 2. encouraging a sitz bath after defecation 3. instilling warm mineral oil into rectum 4. positioning cold compress against the anus

Answer: 1 Rationale: lubricant reduces friction, which facilitates passage of hard, dry stool. A sitz bath requires a practitioners order and thus is not an independent action of the nurse, as does instilling a warm mineral oil. a warm compress may facilitate defecation, but a cold compress will not.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the IV line without the use of a pump. 2. Contact the electrical maintenance department for assistance. 3. Plug in the pump cord in the available plug above the room sink. 4. Use an extension cord from the nurses' lounge for the pump plug.

Answer: 2 Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise, it presents a physical hazard. An IV line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain.Which action should the nurse take next? 1. Check the client's temperature. 2. Isolate the client in a private room. 3. Check a complete set of vital signs. 4. Contact the primary health care provider.

Answer: 2 Rationale: The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Nigeria. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0° C (100.4° F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the primary health care provider and other state and local authorities of the client's signs and symptoms.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

Answer: 2 Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

A school nurse is planning a health class about bodily functions . What information should be included regarding the purpose of mucus in the GI tract? 1. activates digestive enzymes 2. protects gastric mucosa 3. enhances gastric acidity 4. emulsifies fats

Answer: 2 Rationale: mucus protects body surfaces from friction and erosionpresence of fluid or food activates digestive enzymes. does not enhance gastric acidity, and low surface tension of fats of bile salts contributes to emulsification of fats in intestine.

A nurse identifies that a patient understands the need to reestablish bowel flora after a week of diarrhea when the patient states, "I'm going to..." 1. wean myself off antibiotics one day after my temperature is normal 2. eat a container of yogurt every day for a few days 3. add rice to diet one meal each day 4. drink eight glasses of water each day

Answer: 2 Rationale: water is essential for all body processes and to replace fluid lost in diarrhea but it does not reestablish bowel flora

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

Answer: 3 Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

A nurse is caring for a patient with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? 1. using sterile technique when irrigating the tube 2. recording intake an output every 2 hours 3. maintaining suction at the prescribed level 4. providing oral hygiene every 4 hours.

Answer: 3 Rationale: maintaining suction at the prescribed level. (low suction is 80 -100 and high suction is 100-120.oral hygiene should be provided more frequently than every 4 hours. I&O does not need to be recorded this frequently. Medical, not surgical asepsis is necessary.

The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

Answer: 4 Rationale: The nurse should instruct the AP to check safety devices for tightness every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked by the registered nurse every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate a perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, board-like abdomen

Answer: A rigid, board-like abdomen. Rationale: Perforation is an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

A nurse is providing education to a client with a peptic ulcer. Which might the nurse include in the teaching? Select all that apply. a. Avoid caffeine and chocolate b. Avoid smoking and drinking alcohol c. Find ways to reduce stress d. Lie down after meals e. Do not take aspirin or NSAIDs

Answer: Avoid caffeine and chocolate, avoid smoking and drinking alcohol, find ways to reduce stress and do not take aspirin and NSAIDs. Rationale: This answer is correct because caffeine and chocolate increases acid production in the stomach, which can damage the stomach lining and lead to the formation of an ulcer. Smoking increases the patient's risk of an H. pylori infection. Smoking is also harmful to the mucosa of the stomach because the ethanol makes the stomach lining more susceptible to ulceration. Stress increases the likelihood of health risk behaviors such as smoking and drinking. It is debatable if stress increases stomach acid production which irritates the lining of the stomach and intestines. Stress does make the symptoms of peptic ulcers worse. Aspirin and NSAIDs block the enzymes and prostaglandins in the stomach. These provide protection against stomach acid in the mucosa. Aspirin is also an antiplatelet and can cause bleeding in the stomach which can irritate a peptic ulcer.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? a. Obtain a court order for the surgery b. Have the charge nurse sign the informed consent immediately c. Send the client to surgery without the consent form being signed d. Obtain a telephone consent from a family member, following agency policy

Answer: Obtain telephone consent from a family member, following agency policy. Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a surgeon is permitted legally to perform surgery without consent, but the data in the question does not indicate an emergency.

A client recently diagnosed with peptic ulcer disease on warfarin has been prescribed pantoprazole. The nurse contacts that client's health care provider (HCP) with this information and pays close attention to which lab? a. Hct &Hgb b. PT/INR c. PLT d. UA

Answer: PT/INR Rationale: This answer is correct because using proton pump inhibitors with warfarin can possibly increase the effects of warfarin. Prolonged INR can cause life-threatening bleeding. If any increase in the INR is indicated, warfarin should be adjusted to maintain the desired level of anticoagulation.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? a. Weight loss b. Nausea and vomiting c. Pain relieved by food intake d. Pain radiating down the right arm

Answer: Pain relieved by food intake. Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with a duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are mor typical in the client with a gastric ulcer.

The nurse is caring for a client with intestinal obstruction. Which of the following is the priority nursing intervention? A. Retention enema to relieve pressure B. NG tube for intestinal decompression C. Clear liquid only for ease of digestion D. Heat to the abdomen to improve discomfort

Correct Answer: B The priority nursing intervention for a client with intestinal obstruction is to provide them with an NG tube or pump for intestinal decompression. They do not need an enema and should be NPO. Heat application to the abdomen will not help.

Claire, a 33 yr. old is on your floor with a possible bowel obstruction. Which intervention is a priority for her? A. Obtain daily weights. B. Measure abdominal girth. C. Keep strict intake and output. D. Encourage her to increase fluids.

Correct Answer: B. Measure abdominal girth. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention. Abdominal girths should be measured daily. Use the same measuring tape each time. Place the patient in the same position each time. Ensure that the tape measure is placed in the same position each time. This can be done by drawing small tick marks on the patient's abdomen to indicate the position of the tape. Measure the patient at the same time each day.

Five days after undergoing surgery, a client develops a small bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority? A. Imbalanced nutrition: Less than body requirements B. Acute pain C. Deficient fluid volume D. Excess fluid volume

Correct Answer: C. Deficient fluid volume Fluid shifts to the site of the bowel obstruction, causing a fluid deficit in the intravascular spaces. Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses (diaphoresis). Measure urine specific gravity; observe for oliguria. This provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

The nurse is caring for a client with a bowel obstruction. The client has a nasogastric tube in place set to low intermittent suctioning (LIS). The nurse notes an output of 750 mL during the first half of the shift. The nurse reviews the client's lab values and notes a pH of 7.48, CO2 of 35 mEq/L, and HCO3 of 28 mEq/L. Which of the following conditions does the nurse suspect? A. Respiratory alkalosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

Correct Answer: C. Metabolic alkalosis This client's lab values indicate metabolic alkalosis. The client's pH is high, indicating alkalosis. The CO2 is normal, and the bicarbonate is high, which indicates a metabolic source. The nurse can conclude that the loss of acid is due to the high output of the nasogastric tube. Regarding B, the client is losing acidic stomach contents, and the pH of the blood is alkaline, so it is not metabolic acidosis. Regarding C and D, there is no indication of a respiratory issue.

Which of the following positions should the client with appendicitis assume to relieve pain? A. Prone B. Sitting C. Supine D. Lying with legs drawn up

Correct Answer: D Rationale: Lying still with legs drawn up towards the chest helps relieve tension on the abdominal muscle, which helps to reduce the amount of discomfort felt. Lying flat or sitting may increase the amount of pain experienced.

The nurse caring for a client with small bowel obstruction would plan to implement which nursing intervention first? A. Administering pain medication B. Obtaining a blood sample for laboratory studies C. Preparing to insert a nasogastric (NG) tube D. Administering I.V. fluids

Correct Answer: D. Administering I.V. fluids. I.V. infusions containing normal saline solution and potassium should be given first to maintain fluid and electrolyte balance. Maintenance of bowel rest requires alternative fluid replacement to correct losses and anemia. Fluids containing sodium may be restricted in the presence of regional enteritis.

Which of the nursing interventions should be implemented to manage appendicitis? a. Assess pain b. encourage oral intake of clear fluids. c. provide discharge teaching D. assess for symptoms of peritonitis.

Correct answer D Rationale: Monitor for peritonitis because if the appendix ruptures, bacteria can enter the peritoneum. Pain will be managed with analgesics, and pt should be NPO for surgery. Discharge is not done at this time

The nurse is assessing an adolescent who is admitted to the hospital with appendicitis. The nurse should report which of the following to the HCP? 1) change in pain rating of 7 to 8 on a 10 point scale. 2) sudden relief of sharp pain, shifting to diffuse pain. 3) shallow breathing with normal vital signs. 4) decrease the pain rating from 8 to 6 when parents visit.

Correct answer: 2 Rationale: The nurse notifies the HCP if the client has sudden relief of sharp pain and in presence of more diffuse pain. This change in the pain indicates the appendix has ruptured. The diffuse pain is typically accompanied by rigid guarding of the abdomen, progressive abdominal distension, tachycardia, pallor, chills, and irritability. The slight increase in pain can be expected; the decrease in pain when parents visit may be attributed to being distracted from the pain.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications? 1. Deficient fluid volume. 2. Intestinal obstruction. 3. Bowel ischemia. 4. Peritonitis.

Correct answer: 4 Rationale: Complications of acute appendicitis are perforation, peritonitis, and abscess development. Signs of the development of peritonitis include abdominal pain and distention, tachycardia, tachypnea, nausea, vomiting, and fever. Because peritonitis can cause hypovolemic shock, hypotension can develop. Deficient fluid volume would not cause a fever. Intestinal obstruction would cause abdominal distention, diminished or absent bowel sounds, and abdominal pain. Bowel ischemia has signs and symptoms similar to those found with intestinal obstruction.

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant

Correct answer: D Rationale: The pain of acute appendicitis localizes in the right lower quadrant (RLQ) at McBurney's point, an area midway between the umbilicus and the right iliac crest. Often, the pain is worse when manual pressure near the region is suddenly released, a condition called rebound tenderness.

patient is being transferred to your unit with acute cholecystitis. In report the transferring nurse tells you that the patient has a positive Murphy's Sign. You know that this means: a) The patient stops breathing in when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line. b) The patient stops breathing out when the examiner palpates under the ribs on the right upper side of the abdomen at the midclavicular line. c) The patient verbalizes pain when the lower right quadrant is palpated. d) The patient reports pain when pressure is applied to the right lower quadrant but then reports an increase in pain intensity when the pressure is released.

The answer is A. Murphy's Sign can occur with cholecystitis. This occurs when the patient is placed in the supine position and the examiner palpates under the ribs on the right upper side of the abdomen. The examiner will have the patient breathe out and then take a deep breath in. The examiner will simultaneously (while the patient is breathing in) palpate on this area under the ribs at the midclavicular line (hence the location of the gallbladder). It is a POSITIVE Murphy's Sign when the patient stops breathing in during palpation due to pain.

A patient, who has recovered from cholecystitis, is being discharged home. What meal options below are best for this patient? a) Baked chicken with steamed carrots and rice b) Broccoli and cheese casserole with gravy and mashed potatoes c) Cheeseburger with fries d) Fried chicken with a baked potato

The answer is A. The patient should eat a low-fat diet and avoid greasy/fatty/gassy foods. Option B is wrong because this contains dairy/animal fat like the cheese and gravy, and broccoli is known to cause gas. Option C and D are greasy food options.

1. The gallbladder is found on the __________ side of the body and is located under the ____________. It stores __________. a) right; pancreas; bilirubin b) left; liver; bile c) right; thymus' bilirubin d) right; liver; bile

The answer is D. The gallbladder is found in the RIGHT side of the body and is located under the LIVER. It stores BILE.

Your recent admission has acute cholecystitis. The patient is awaiting a cholecystostomy. What signs and symptoms are associated with this condition? Select all that apply: a) Right lower quadrant pain with rebound tenderness b) Negative Murphy's Sign c) Epigastric pain that radiates to the right scapula d) Pain and fullness that increases after a greasy or spicy meal e) Fever f) Tachycardia g) Nausea

The answers are C, D, E, F, and G. Option A and B are not associated with cholecystitis, but a POSITIVE Murphy's Sign is.

You're providing a community in-service about gastrointestinal disorders. During your teaching about cholecystitis, you discuss how cholelithiasis can lead to this condition. What are the risk factors for cholelithiasis that you will include in your teaching to the participants? Select all that apply: a) Being male b) Underweight c) Being female d) Older age e) Native American f) Caucasian g) Pregnant h) Family History i) Obesity

The answers are C, D, E, G, H and I. Cholelithiasis is the formation of gallstones. Risk factors include: being female, older age (over 40), Native American or Mexican American descent, pregnant, obesity, and family history.