Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures

The nurse is palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant. How deep should the nurse depress this patients abdomen? a. 1 inch b. 2 inches c. 3 inches d. 4 inches

ANS: A When palpating the abdomen of a patient reporting mild abdominal pain in the upper right quadrant, the LPN should depress the abdomen no more than 1 inch. B. C. D. Deep palpation of the abdomen is done only by physicians and highly skilled nurses.

The nurse is participating in a local health fair. Which should the nurse include in a presentation on aging changes associated with the GI system? (Select all that apply.) a. Decreased peristalsis b. Increased constipation c. Decreased sense of taste d. Increased periodontal disease e. Decreased risk of colon cancer

ANS: A, B, C, D The sense of taste becomes less acute, and there is greater likelihood of periodontal disease and oral cancer. There may be difficulties with chewing if teeth have been lost. Secretions throughout the GI tract are reduced, and the effectiveness of peristalsis diminishes because of loss of muscle elasticity and slowed motility. Indigestion may become more common, especially if the lower esophageal sphincter (LES) loses its tone, and there is greater chance of peptic ulcer. In the colon, diverticula may form. Constipation may be a problem, as may hemorrhoids. E. The risk of colon cancer also increases with age.

The nurse is caring for a patient of Mexican American descent who is experiencing diarrhea. Which foods should the nurse expect the patient to select for the next days meals? (Select all that apply.) a. Fish b. Beef c. Cheese d. Chicken e. Fresh Fruit

ANS: A, D, E Diarrhea is considered a hot disease and would be treated by eating cold foods such as fish, chicken, and fresh fruit. B. C. These food items are considered hot substances, used to treat cold health problems.

The nurse is reviewing structures within the hepatobiliary system with a patient with liver disease. Which structures should the nurse identify as being a part of this system? (Select all that apply.) a. Liver b. Colon c. Jejunum d. Bile duct e. Esophagus f. Gallbladder

ANS: A, D, F The liver, bile duct, and gallbladder make up the hepatobiliary system. B. C. E. These organs are a part of the GI system.

The nurse is contributing to a patients plan of care. Which patients should the nurse recommend as benefiting from PN? (Select all that apply.) a. A patient who has esophageal cancer b. A patient scheduled for toe amputation c. A patient who has just had an appendectomy d. A patient who has been admitted with chest pain e. A patient with severe burns across the face and chest f. A patient who has respiratory distress from emphysema

ANS: A, E Patients with conditions such as burns, trauma, cancer, AIDS, malnutrition, anorexia nervosa, or fever, or those undergoing major surgery may need PN. The patient with esophageal cancer or burns across the face and chest may have difficulty swallowing and need nutritional support via PN. B. C. D. F. These patients may not necessarily benefit from PN.

The nurse is assisting with the care of a patient who has PN infusing. Which data should be the most concerning to the nurse? a. Heart rate 92 beats/min b. Respiratory rate 16/min c. Blood glucose 260 mg/dL d. Urine output 60 mL in the past hour

ANS: C The glucose level is elevated. It is important to monitor glucose levels as ordered and to look for signs of hyperglycemia due to the high dextrose in PN. A. B. D. This data is all within normal limits.

The nurse is caring for a patient who has a permanent gastric feeding tube. What nursing action would be most helpful to prevent aspiration during feedings? a. Administer careful oral care daily. b. Check placement of the tube hourly. c. Elevate head of bed at least 30 degrees. d. Ask the physician to order daily x-rays.

ANS: C To prevent aspiration during tube feedings the nurse should elevate the head of the patients bed more than or equal to 30 degrees at all times for feeding. A. B. D. These actions would not prevent the patient from developing aspiration with tube feedings.

The nurse is caring for a patient on a clear liquid diet. The nurse should recognize that the patient requires further teaching if the patient requests which food? a. Gelatin b. Beef broth c. Cranberry juice d. Coffee with cream

ANS: D Cream is not on a clear liquid diet. A. B. C. Clear liquids are liquid items that you can see through.

A patients Levin NG tube inserted for decompression of the bowel, which is connected to low intermittent suction, is not draining. The patient reports feeling full, uncomfortable, and nauseous. After verifying tube placement, what action should the nurse take next? a. Provide an antiemetic. b. Remove the nasogastric tube. c. Notify the physician immediately. d. Gently irrigate tube with normal saline.

ANS: D Gently irrigate the tube with normal saline to ensure patency and that the tube does not adhere to the stomach wall. A. An antiemetic would not help the tube drain. B. The NG tube cannot be removed without a health care providers (HCPs) order. C. The physician may need to be notified but after an attempt at irrigation is made.

The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose. What action should the nurse take before starting the feeding? a. Listen to bowel sounds. b. Check the pH of gastric aspirate. c. Secure the NG tube with additional tape. d. Irrigate the tube with 10 mL of sterile water.

b. Check the pH of gastric aspirate. -Prior to instilling anything into the NG tube, it is essential to verify placement of the NG tube; after x-ray is performed, the preferred method of verification is to check the pH of the gastric aspirate. A. Bowel sounds can be auscultated at any time. C. The NG tube should have been secured after insertion. D. The tube is irrigated with normal saline and not sterile water.

The nurse is collecting data from a patient who is scheduled for an ileostomy. Which technique should the nurse use to help identify optimal stoma placement? a. Palpation b. Inspection c. Percussion d. Auscultation

b. Inspection -Inspection is observation. The abdomen is visually inspected to note the condition of the skin, the contour, belt line, and other factors that would affect optimal stoma placement. A. C. D. These techniques of data collection would not be appropriate when determining optimal placement for a stoma.

The nurse is preparing to initiate a tube feeding through a patients nasogastric (NG) tube. Prior to initiating this feeding what should the nurse use to irrigate the tube? a. Sterile water b. Normal saline c. Cranberry juice d. Carbonated water

b. Normal saline -Normal saline is used for NG tube irrigation to prevent loss of electrolytes. A. Sterile water could cause an electrolyte imbalance in the patient. C. D. Cranberry juice and carbonated water are not appropriate fluids to flush a nasogastric tube.

The nurse is caring for a patient with cultural dietary needs. Which question should the nurse include in a cultural dietary assessment? a. What restaurants do you go to? b. Which foods do you most commonly eat? c. Which unavailable cultural foods do you prefer to eat? d. What foods are available in the country where you lived?

b. Which foods do you most commonly eat? -Understanding cultural influences, respecting them, and assisting the patient to maintain desired cultural practices are important for nutritional maintenance. Finding out which foods the patient likes will allow for planning to include those foods in meals. A. C. D. These questions do not necessarily assess the patients cultural dietary preferences.

The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding? a. Absent bowel sounds b. Normal bowel sounds c. Hypoactive bowel sounds d. Hyperactive bowel sounds

c. Hypoactive bowel sounds -Hypoactive bowel sounds are bowel sounds that are infrequent (normal is 5 to 30) over a 5-minute period and can occur in patients with a paralytic ileus or following abdominal surgery. A. Since the nurse heard sounds, absent bowel sounds would be incorrect to document. B. Normal bowel sounds occur 5 to 30 times over a 5 minute period. D. Hyperactive bowel sounds would be more than 30 sounds over a 5 minute period.

The nurse is caring for a patient who is placed on a modified bland diet. Which should be removed before serving the patients dinner tray? a. Salt b. Sugar c. Pepper d. Mayonnaise

c. Pepper -Pepper, which is spicy, would not be included in a bland diet. A. B. D. These food items are bland.

A patient receiving 70 mL of tube feeding per hour has a residual amount of 120 mL. What action should the nurse take? a. Slow the feeding to 35 mL/hr. b. Continue the feeding as ordered. c. Increase the feeding to 100 mL/hr. d. Hold the feeding, and notify the physician.

d. Hold the feeding, and notify the physician. -If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. A. Slowing the feeding is not going to reduce the amount of residual. B. Continuing the feeding as ordered increases the patients risk for aspiration or vomiting. C. Increasing the feeding will increase the patients risk for aspiration or vomiting.

A licensed practical nurse (LPN) who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN). Which action should the nurse take? a. Provide patient care as assigned. b. Ask another nurse to trade patients for the shift. c. Notify the supervisor that another nurse will need to be pulled. d. Notify the charge nurse that an adjustment in the patient assignment is necessary.

d. Notify the charge nurse that an adjustment in the patient assignment is necessary. -Usually, registered nurses (RNs) are responsible for administering PN. Therefore, the LPN should discuss the assignment with the charge nurse and seek a possible adjustment. A. Providing patient care as assigned would be beyond the LPNs scope of practice. B. The LPN cannot make a patient care assignment change. C. The LPN needs to work through the charge nurse.

The nurse is caring for a patient recovering from an endoscopic retrograde cholangiopancreatography (ERCP). Which findings should the nurse report to the charge nurse immediately? (Select all that apply.) a. Nausea and vomiting b. Onset of a fever and chills c. Urine output 100 mL the last hour d. Heart rate of 110 beats per minute e. Increased right upper quadrant pain

ANS: A, B, D, E After an ERCP the nurse should report nausea and vomiting, onset of fever and chills, rapid heart rate, and increased right upper quadrant pain which could indicate an infection or perforation of the pancreas. C. Urine output of 100 mL the last hour would not need to be reported to the charge nurse.

A patient is upset to learn that an occult blood test of a stool specimen was positive for blood. What should the nurse assess in this patient to determine if the results were falsely positive? (Select all that apply.) a. Ingestion of fish b. Use of aspirin or NSAIDs c. Recent intake of whole milk and cheese d. Ingestion of red meat three days before the test e. Recent dental procedure causing bleeding gums

ANS: A, B, D, E False-positive occult blood results can occur with bleeding gums following a dental procedure; ingestion of red meat within 3 days before testing; ingestion of fish, and use of drugs, including aspirin and NSAIDs. C. Whole milk and cheese are not identified as causing a false positive occult blood test of a stool specimen.

The nurse is reinforcing teaching for a patient who is on a clear liquid diet. Which patient statement(s) indicates correct understanding of the foods that would be appropriate on this diet? (Select all that apply.) a. Beef broth b. Grape juice c. Apple juice d. Orange gelatin e. Tea with sugar f. Vanilla ice cream

ANS: A, C, D, E Clear liquids are liquid items that you can see through. B. F. Ice cream and grape juice are not on a clear liquid diet.

The nurse is reinforcing teaching for a patient who has hepatitis. Which functions of the liver should the nurse include in the teaching? (Select all that apply.) a. Form bilirubin b. Produce white blood cells c. Synthesize clotting factors d. Store sodium and potassium e. Synthesize essential amino acids f. Phagocytize worn red blood cells

ANS: A, C, F The liver forms bilirubin, synthesizes clotting factors, and phagocytizes worn out red blood cells. B. D. E. These actions are performed by other body organs or functions.

The nurse is contributing to the teaching plan for another nurses team of patients. Which patients should the nurse expect to be scheduled for an upper GI series? (Select all that apply.) a. A 45-year-old with a suspected hiatal hernia b. A 19-year-old with symptoms of appendicitis c. A 52-year-old with a family history of polyps d. A 78-year-old who has frank blood in his stool e. A 65-year-old who is receiving treatment for hemorrhoids f. A 33-year-old who is experiencing symptoms of pyloric stricture

ANS: A, C, F Upper GIs are used to detect such things as strictures, ulcers, tumors, polyps, hiatal hernias, and motility problems in the upper GI tract. E. Hemorrhoids are not detected or treated with an upper GI series. B. Appendicitis is not detected with an upper GI series. D. Frank blood in the stool is indicative of a lower GI problem.

While assessing a patients abdomen, the nurse notes a yellow-tinge to the skin. How should the nurse document this finding? a. Striae b. Jaundice c. Caput medusae d. Spider angioma

ANS: B Yellowing of the skin is termed jaundice. A. Striae are light silver-colored or thin red lines on the skin. C. Caput medusae are bluish purple swollen vein patterns extending out from the navel. D. Spider angiomas are thin reddish purple vein lines close to the skin surface.

A patient is diagnosed with liver failure. Which vitamin supplements should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Vitamin C b. Vitamin D c. Vitamin K d. Vitamin B6 e. Vitamin B12

ANS: B, C, E The liver stores the fat-soluble vitamins A, D, E, and K and the water-soluble vitamin B12. A. Vitamin C is a water-soluble vitamin that is not stored in the liver. D. The liver does not store Vitamin B6.

The nurse is caring for a patient on a full liquid diet. The nurse recognizes that the patient understands teaching if the patient requests which food item? a. Salad b. Cheese c. Milkshake d. Hamburger

ANS: C A full liquid diet is any item that is liquid at room temperature as a milkshake would be. A. B. D. These food items are appropriate for a regular diet.

A patient recovering from GI surgery 4 hours ago is alert and oriented and complains of feeling thirsty. Diet orders read, clear liquids, advance as tolerated. Which action should the nurse take? a. Notify the RN. b. Ask the patient if she has passed any flatus. c. Allow the patient to take small sips of water. d. Inform the patient she must remain NPO (nothing by mouth) until she has bowel sounds.

ANS: C Because there is an order for liquids and the patient is stable, the nurse can provide the patient with sips of fluid. A. RN does not need to be informed prior to giving the fluids. B. D. There does not appear to be an advantage to maintaining patients NPO postoperatively until bowel function returns. If ordered, nutrition can be provided to patients undergoing GI surgery early postoperatively which may improve their recovery with fewer complications.

The nurse is preparing a patient for an NG tube insertion. To decrease the patients anxiety about insertion of a nasogastric tube, what should the nurse do? a. Administer a narcotic. b. Administer a sedative. c. Explain the procedure. d. Assess the patients gag reflex.

ANS: C Explaining what is to be done reduces patient anxiety because the patient knows what to expect and can prepare to cope with it. A. B. A narcotic or sedative is not helpful when inserting an NG tube into a patient. D. The patients gag reflex will be assessed during tube insertion.

The nurse is reinforcing teaching provided to a patient with a peptic ulcer. Which patient statement indicates understanding about the function of hydrochloric acid in gastric juice? a. Digestion of starch b. Inactivation of pepsin c. Destruction of pathogens d. Maintenance of a pH of 7 to 8

ANS: C Hydrochloric acid creates the pH of 1 to 2 that is necessary for pepsin to function and to kill most microorganisms that enter the stomach. A. B. D. These responses do not explain the function of hydrochloric acid in gastric juice.

The nurse is caring for a patient who has a non-vented nasogastric tube. Which suction setting should the nurse select? a. Low continuous suction b. High continuous suction c. Low intermittent suction d. High intermittent suction

ANS: C If suction is ordered, low intermittent suction is used with non-vented nasogastric tubes (Levin). A. B. D. These settings are inappropriate for this type of nasogastric tube.

A patient is prescribed PN. For which percentage of dextrose should the nurse prepare the patient to have a central venous catheter placed for this infusion? a. 5% b. 8% c. 10% d. 12%

ANS: D PN dextrose greater than 12% should be administered through a central venous catheter into a large vein to prevent vein irritation and thrombophlebitis. A. B. C. These dextrose percentages can be safely administered through a peripheral site.

The nurse is assisting with the care of a patient who has PN containing dextrose 50% infusing. The patient asks why the rate keeps being increased. How should the nurse respond to this patient? a. It is important to increase the PN whenever your blood sugar is low. b. It is important to do this to help reduce bile secretion and prevent heartburn. c. By changing the rate, it helps your body increase absorption of the electrolytes. d. It is started slowly and increased slowly to allow your pancreas to adjust insulin levels.

ANS: D PN is started slowly to give the pancreas time to adjust to increasing insulin production for the high amounts of glucose in the PN. A. The rate is not changed because the patients blood sugar is low. B. The rate is not changed because of bile secretion or heartburn. C. The rate is not changed to encourage the body to absorb electrolytes.

The nurse is reinforcing teaching for a patient who is scheduled for an esophagogastroduodenoscopy. Which patient statement indicates understanding of pre-procedure diet instructions? a. I may have a full liquid breakfast. b. I will not eat or drink 12 hours before the procedure. c. I can drink only clear liquids 2 hours before the procedure. d. I will have nothing to eat or drink 8 to 12 hours before the procedure.

ANS: D The patient will have nothing to eat or drink 8 to 12 hours typically before the procedure. A. B. C. These statements indicate the patient does not understand the pre-procedure diet instructions.

The nurse is reinforcing teaching provided to a patient who has a small bowel obstruction. Which processes occur in the small intestine that should be included in this teaching? (Select all that apply.) a. Production of bile b. Absorption of water c. Production of insulin d. Mechanical digestion of food to chyme e. Production of enzymes to complete carbohydrate metabolism f. Production of peptides to complete the digestion of proteins to amino acids

ANS: E, F Enzymes to complete carbohydrate metabolism and production of peptides to digest proteins occur in the small intestines. A. B. C. D. These processes occur in other body organs.

A patient receiving a tube feeding at 60 mL/hr has a residual of 10 mL. What action should the nurse take? a. Continue the feeding as ordered. b. Slow the feeding to 35 mL/hour. c. Decrease the feeding to 10 mL/hour. d. Hold the feeding, and notify the physician.

a. Continue the feeding as ordered. -If the residual amount is more than 100 mL or the amount specified by the agency or physician, the feeding should be stopped to prevent vomiting or aspiration and the physician notified. This feeding can be continued as ordered, as the residual amount is only 10 mL. B. C. D. The feeding does not need to be slowed, decreased, or held.

The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used? a. Palpation b. Inspection c. Percussion d. Auscultation

a. Palpation -Light palpation uses touch and depresses the abdomen 0.5 to 1 inch. B. Inspection is looking at or observing an area. C. Percussion is using the hands and fingers to produce a sound that identifies the density of the organs beneath the area being percussed. D. Auscultation is the use of a stethoscope to listen for sounds.

A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy. Which finding should cause the nurse to clarify routine preparation orders with the physician? a. The patients age b. Presence of severe diarrhea c. Complaints of abdominal cramping d. Patients weight is 10% below ideal body weight

b. Presence of severe diarrhea -Routine preparation with severe diarrhea can result in electrolyte imbalance. Bowel preparation may not be ordered for patients with bleeding or severe diarrhea. A. C. D. The patients age, complaints of abdominal cramping, or current weight are not contraindications for the routine preparation for this diagnostic test.

A patient receiving tube feedings at 50 mL/hour has a residual volume of 250 mL of undigested tube feeding. What action should the nurse take? a. Discard aspirated tube feeding, and run tube feeding as ordered by the physician. b. Report amount of aspirated tube feeding to the RN for consultation with the physician. c. Return aspirated tube feeding to the patient, and run feeding at a slower rate of 20 mL/hour. d. Return aspirated tube feeding to the patient, and wait 2 hours before restarting tube feeding at 50 mL/hr.

b. Report amount of aspirated tube feeding to the RN for consultation with the physician. -As the residual amount is more than 100 mL or the amount specified by the agency or physician, the RN and the physician are notified, and the feeding will likely be stopped to prevent vomiting or aspiration. A. C. D. The nurse should not continue this tube feeding because of the risk of vomiting or aspiration.

While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level. How should the nurse interpret this test result? a. The patient is cured. b. The patient has a residual or recurrent tumor. c. The liver has been damaged by chemotherapy. d. The patient should be placed in protective isolation

b. The patient has a residual or recurrent tumor. -CEA and carbohydrate antigen 19-9 are markers used to monitor gastrointestinal (GI) cancer treatment effectiveness and detect recurrence. A. An elevated level does not indicate that the patient is cured. C. An elevated CEA level would not be seen in the absence of disease and does not indicate liver function. D. Extremely low white blood cell counts would be used to determine if the patient needed to be placed in protective isolation.

The nurse is inspecting a patients oral cavity. What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient? a. Loose teeth are unsightly to the patient. b. Loose teeth can cause dental abscesses. c. Loose teeth can be aspirated into the airway. d. Loose teeth can prevent the patient from eating.

c. Loose teeth can be aspirated into the airway. -Loose teeth can be aspirated into the airway and become a choking risk. A. The nurse is not inspecting for loose teeth because it is unsightly to the patient. B. The nurse is not inspecting for loose teeth because of the risk for dental abscesses. D. Missing teeth is more likely to prevent a patient from eating.

The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which action should the nurse take? a. Lay the patient supine. b. Elevate the head of the bed 10 degrees. c. Place the patient in high Fowlers position. d. Place the patient onto the left side with knees flexed.

c. Place the patient in high Fowlers position. -When feedings are administered, patients must be positioned in a sitting or high Fowlers position to reduce the risk of aspiration. A. B. D. These positions increase the patients risk of aspiration.

The nurse is reviewing GI function with a patient. Which body structure should the nurse emphasize as accomplishing mechanical digestion in the stomach? a. Mucosa b. Gastric glands c. Smooth muscle layers d. Striated muscle layers

c. Smooth muscle layers -The stomach wall has three layers of smooth muscle that provide very efficient mechanical digestion to change food to a thick liquid called chyme. A. B. D. These structures do not perform mechanical digestion in the stomach.

A patient is being prepared for an upper GI series. Which statement indicates that the patient understands the preparation for this test? a. I should eat a soft diet the night before the procedure. b. I must not eat or drink for 4 hours after the procedure. c. Ill be given a clear liquid diet the night after the procedure. d. I cant have anything to eat or drink for 6 to 8 hours before the procedure.

d. I cant have anything to eat or drink for 6 to 8 hours before the procedure. -An appropriate patient diet preparation for an upper GI series is placing the patient on NPO restriction 6 to 8 hours before the procedure for best visualization. A. B. C. These statements indicate that the patient does not understand the correct way to prepare for this diagnostic test.

The nurse is caring for a patient whose NG tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which action should the nurse take? a. Advance the NG tube 2 inches. b. Change the suction setting to high. c. Reinsert the NG tube in the other nare. d. Irrigate the NG tube with 30 milliliters of normal saline.

d. Irrigate the NG tube with 30 milliliters of normal saline. -The nurse should irrigate the NG tube with 30 mL of normal saline to see if it is obstructed or on the stomach wall. B. Suction should remain on a low setting to prevent damage to the lining of the stomach. A. The tube should not be advanced without an HCPs order. C. The NG tube should not be pulled and reinserted without an HCPs order.

The nurse is reinforcing teaching for a patient who is scheduled for an upper GI series. Which patient statement indicates teaching has been effective? a. It is an estimated rectal cholangiopancreatophonography. b. It is a scope inserted into the duodenum with dye injection. c. It is a sigmoidoscopy with radiography after injection of dye. d. It is an x-ray of the esophagus, stomach, and duodenum using barium.

d. It is an x-ray of the esophagus, stomach, and duodenum using barium. -An upper GI is an x-ray of the esophagus, stomach, and duodenum using barium. A. B. C. These statements do not correctly explain an upper GI series.