gastrointestinal part 1
The nurse is providing instructions to a patient with hemorrhoids. The nurse should recommend which of the following?
"Apply cold packs to the rectal area" "Increase fluid intake""Increase fiber intake" "Sit on a pillow if you work at a desk for long periods of time" Explanation • The patient should increase fiber and fluid intake to promote defecation without straining. • Cold packs can be applied to the rectal area to relieve discomfort and inflammation. • Sitting on a pillow can relieve pressure if sitting for long periods is necessary. • Daily laxative use can lead to dependency and is not a good long term option.
The nurse is caring for a patient diagnosed with shigellosis. Which of the following statements made by the patient indicates the need for additional medical counseling?
"I can prevent this disease in the future by coughing in my cuff, not my hand" Explanation • Shigellosis, or dysentery, is a foodborne illness, transmitted directly from person-to-person through the mouth. • Shigellosis is caused by a bacteria. It causes dysentery, diarrhea, cramps, nausea, vomiting, and fever. • Strict enteric precautions should be maintained to prevent the spread of infection to family and friends.
A patient is to undergo an endoscopic retrograde cholangiopancreatography (ERCP), and it is the nurse's responsibility to provide education before and after the procedure. Which of the following statements by the patient indicates a need for further teaching?
"I can take sips of water after the procedure." Explanation • The correct answer should identify the statement that indicates that the teaching was ineffective. • Any food or fluid is contraindicated after the procedure to prevent aspiration. • The patient should be NPO 8-12 hours before the procedure and after the procedure until gag reflex has returned to normal. • The remaining answer choices show that the patient understood the instructions.
The nurse is providing colostomy education to a patient prior to discharge. The nurse knows that the patient did not understand the instructions when he states:
"I must rub the skin area and stoma before applying the adhesive." Explanation • Rubbing the stoma and skin area around it can abrade the skin and may cause further trauma to the ostomy. • It is best to pat dry the stoma and skin area around the ostomy before placing the barrier and adhesive to ensure that it will adhere to the skin. • Other choices are the proper techniques in caring for an ostomy and its appliance. • To change an ostomy, the patient is taught to first empty it by releasing the clamp on the bottom of the pouch over a basin or the toilet. The contents may then be emptied and the clamp re-applied. Next, the patient should press on the skin around the ostomy to loosen the seal, then remove the pouch, gently clean and dry the skin and inspect the stoma, and attach the new ostomy appliance with adhesive (it may be a glue or a self-stick ostomy). A new pouch is then attached.
A nurse is instructing a patient recently diagnosed with a hiatal hernia. Which of the following statements made by the patient indicates an understanding of this condition?
"I will avoid eating for at least two hours before bed." "I will eat small meals and avoid spicy food." "I will avoid lifting heavy objects." Explanation • In order to decrease gastric reflux, the patient should eat small, bland meals. • Patients should be instructed to sit up for at least an hour after a meal and to avoid eating anything for at least two hours before bed. • The patient should avoid heavy lifting to minimize intra-abdominal pressure. • A hiatal hernia is the protrusion of the upper portion of the stomach into the chest. In a hiatal hernia, part of the stomach and/or the gastroesophageal junction slips through the opening in the diaphragm (called the hiatus) and into the chest. This can cause gastric reflux, Barrett's esophagus, and increase the risk of developing esophageal cancer. • There are two types of hiatal hernias: • Sliding hiatal hernias allow part of the stomach and the gastroesophageal junction to slip into the chest. These are common in smokers, patients with obesity, and women older than 50. Activities or conditions that increase pressure and worsen these hernias include heavy coughing, straining while defecating, sudden physical exertion, and pregnancy. • Paraesophageal hernias are more likely to cause severe symptoms because a small portion of the stomach becomes trapped in the diaphragm and chest, pinched in the gastroesophageal junction. • Patients with hiatal hernias will not see any visible signs. A visible lump near the groin may be associated with an inguinal hernia.
A patient is admitted for gastric bypass surgery. Which of the following patient statements indicates a need for further patient teaching?
"I will finally be thin and can eat anything I want" Explanation • Gastric bypass alone will not cure obesity or the chronic conditions associated with obesity. The patient needs to change their lifestyle through proper diet, exercise, and avoiding tobacco.
The nurse is educating a patient with cirrhosis about lifestyle changes. Which of the following statements by the patient indicates the need for additional education?
"I will take acetaminophen (Tylenol) if I get a fever" Explanation • Acetaminophen can cause liver damage, especially in patients with cirrhosis. • The patient with cirrhosis should get adequate sleep, monitor their weight, and eat an increased amount of carbohydrates.
The nurse is administering an enema to a client. The nurse positions the client side-lying and inserts the lubricated tip of the enema applicator to a depth of:
3-4 inches. Explanation • Lubricate the enema applicator tip. Insert the lubricated enema tip 3-4 inches into the rectum and release the enema tubing clamp. • Monitor the client for cramping and muscle tension as the solutions flows into the rectum. If the client reports discomfort, stop the flow for a few moments until it subsides. Massaging the abdomen can relieve some discomfort. Massage in the direction that content moves along in the GI tract. • Remove the tip of the enema from the rectum once it is empty. Have the client to remain laying down until he or she feels the need to void, then help him or her to the restroom.
A nurse is caring for a hospitalized client who was admitted for GI bleeding with a history of gallstones. Which of the following findings would the nurse report to the physician immediately?
300 ml of emesis with fecal components Explanation •A finding of emesis with fecal components may indicate that an intestinal obstruction has formed, leading to back up in the GI tract, and would indicate a change or worsening in the client's condition. The physician should be called for this. •A finding of coffee ground emesis is an indication of a slow GI bleed, which the client was admitted for and of which the physician is already aware. •Yellow/green emesis and bitter tasting emesis contains bile which is not indicative of a change or a critical condition.
A nurse is assessing a patient with acute pancreatitis. The nurse should be aware of which assessment findings that support the diagnosis?
Abdominal pain Fever nausea vomiting Explanation • Acute pancreatitis can cause an elevated temperature, weight loss, abdominal pain, nausea, and vomiting. • Abdominal pain in acute pancreatitis is classically described as sharp epigastric pain that radiates into the back. • The other options are not associated with pancreatitis.
The nurse is instructing a patient diagnosed with acute gastritis. The patient asks about the causes of gastritis. The nurse should include which of the following risk factors in her response?
Alcohol use Trauma Stress NSAID use Explanation • Gastritis, inflammation of the stomach lining, has many causes. Stress is thought to cause gastritis through decreased blood flow to the mucosal lining of the stomach, which leads to atrophy or death of the protective cells, making it easier for the gastric acids to cause damage. • NSAIDs prohibit Cox-1, a prostaglandin needed in the protective mucosal lining of the stomach. If Cox-1 prostaglandins are not produced the mucosal lining is more susceptible to damage from gastric acids. • All of the following risk factors cause gastritis through direct irritation or disruption of the mucosal lining: Alcohol (toxins), trauma, H. pylori (bacterial infection in the stomach), surgery, and burns. • Inactivity and dairy are not associated with gastritis.
The nurse is caring for a patient with fulminant ulcerative colitis. The nurse would be alert for which of the following symptoms associated with severe fulminant ulcerative colitis?
Anemia Toxic megacolon 10 or more bowel movements per day Bowel perforation Explanation • Ulcerative colitis correlates with bowel ulceration and dilation, leading to malabsorption of nutrients and diarrhea. These patients may have many bowel movements each day, abdominal discomfort, some bloody stools, and anemia. • Fulminant colitis refers to the most severe type of ulcerative colitis. These patients have the symptoms of chronic ulcerative colitis like anemia and malabsorption but more severe manifestations including more than 10 stools per day, continuous bleeding, abdominal pain and distension, and toxic symptoms of fever and anorexia. These patients may progress to toxic megacolon and bowel perforation.
A patient is admitted after complaints consistent with hepatitis A. The patient's blood tests confirm this diagnosis. The nurse should expect to observe which symptoms?
Anorexia Nausea/Vomiting Fatigue Explanation • Hepatitis A is highly contagious and contracted from contaminated food, water, or close contact with an infected person. It is most common in undeveloped countries. Hepatitis A causes liver damage, but most people recover completely. Mild cases often require no treatment. • Classic signs and symptoms of hepatitis A are anorexia, weakness, fatigue, nausea, and vomiting. Other symptoms can also include right upper quadrant (RUQ) abdominal pain, clay-colored bowel movements, dark/brown urine, low-grade fever, or jaundice. • Pain radiating to the shoulder and constipation are not associated with hepatitis A.
A patient with right lower quadrant abdominal pain is suspected of having appendicitis. The nurse explains to the patient that the most common cause of appendicitis is:
Appendix obstruction. Explanation • Obstruction of the appendix is the most common cause of appendicitis, sometimes leading to rupture. • Infections, bowel obstructions, and appendix rupture do not cause appendicitis.
A patient is scheduled to undergo an upper GI endoscopy for the diagnosis of esophageal varices. The nurse explains to the patient that esophageal varices:
Are common in patients with cirrhosis. Explanation • Esophageal varices are dilated sub-mucosal veins in the esophagus. They are a consequence of portal hypertension caused by cirrhosis. • Esophageal varices are treated by banding, ligation, or sclerotherapy via endoscopy. • Esophageal varices can have many complications, such as excessive bleeding and infection. • Esophageal varices do not increase the risk of heart failure.
A home health nurse is caring for a 60-year-old male with a hemoglobin of 10.5 g/dl and a hematocrit of 30%. Which of the following actions would be most appropriate?
Ask the patient if he has had any dark or bloody stools Explanation • Normal hemoglobin and hematocrit for a male is 14-18 g/dl and 42-52%. • These values indicate anemia. Anemia could be caused by a GI bleed. The nurse should assess the patient for signs and symptoms of bleeding. • Blood pressure should be checked only after assessing for more common signs of a GI bleed. Anemic patients often have a normal blood pressure. • Sending the patient to the hospital may be needed, but the nurse should assess the situation first. • The hemoglobin and hematocrit should be rechecked frequently if a GI bleed is suspected. • Pernicious anemia is a macrocytic anemia that results when vitamin B12 cannot be absorbed in the distal small intestine because there is a lack of the required intrinsic factor (which is normally produced by parietal cells in the stomach) for this absorption to occur. Pernicious anemia may result after surgical removal of parts of the stomach or from chronic gastritis causing decreased secretion of intrinsic factor. Autoimmune conditions may also produce antibodies against gastric parietal cells. When the production of intrinsic factor declines gradually, symptoms may progress over 20+ years, from mild GI effects and mood swings to weakness and fatigue, paresthesias of feet and fingers, and even cognitive effects and memory deficits, as well as difficulty walking. In later stages, these patients may have a beefy, red tongue and an enlarged liver that can lead to right-sided heart failure. The HGB can be 7-8 g/dL. Treatment requires monthly B12 injections for life. • Folate (folic acid) deficiency is another macrocytic anemia. Folate deficiency is dangerous for unborn infants because folic acid prevents neural tube defects. Pregnant women are recommended to have at least 400 ug/day. Folate is absorbed in the small intestine and stored in the liver. Alcoholism or a diet low in vegetables can lead to folate deficiency. Patients with folate deficiency may develop stomatitis and ulcerations on the tongue. They may have dysphagia, flatulence, and watery diarrhea. • Iron deficiency anemia is a microcytic anemia often caused by chronic blood loss from minor gastrointestinal bleeding or colon cancer. Over time, the demands for iron exceed intake. Even blood loss of 10-20 milliliters of red cells per day is more iron a person can absorb in the diet. Manifestations of iron deficiency anemia include fatigue, pallor, fissures at the corners of the mouth, spooning of fingernails, and reduced exercise tolerance. Anemia is defined as HGB < 13 g/dL for men and <12 g/dL for women. • Thalassemia major or Cooley's anemia is a disorder caused by defects in both beta-chains of the hemoglobin molecule, result in a severe microcytic anemia. These patients develop facial deformities from expansion of the marrow of the facial bones, including maxillary hyperplasia and frontal bossing. Thalassemia is found most often in Black, Mediterranean, and Southeast Asian ethnic groups. • Aplastic anemia is a normocytic anemia resulting from a decline in blood cell production related to bone marrow depression. (Pancytopenia is often also be seen with this type of anemia, resulting in the decline of all three types of blood cells.) RBC production declines gradually than WBCs or PLTs, so this anemia appears with a chronic pattern. Aplastic anemia can be either hereditary or acquired after birth. If the onset if sudden, symptoms include hypoxia, pallor, weakness, fever, and dyspnea. The slower onset produces progressive weakness, infections, low-grade fever, cellulitis in the neck, nosebleeds, or waxy and pale skin tones. Aplastic anemia can cause an extremely low HGB of 7 g/ dL.
The nurse is caring for a patient with a Miller-Abbott tube used to decompress the small bowel. Which of the following would confirm the tube is located in the small intestine?
Aspirate with a pH above 7 Explanation • The small intestine is alkaline with a pH of 7 or greater. The stomach is acidic and should have a pH lower than 7. • A Miller-Abbott tube is inserted through the nose and advanced past the pyloric valve into the small intestine. It is used to diagnose and treat small bowel obstructions.
A patient with a nasogastric tube (NG) is complaining of abdominal pain and feeling full. The patient underwent a colon resection 2 days ago and states that the discomfort has been progressing. What should the nurse do first?
Assess patency of the NG tube. Explanation • When an NG tube is plugged and the stomach cannot be suctioned, contents may collect in the stomach causing discomfort and fullness. • Checking the patient's vital signs can be done, but NG patency is a priority. • Although the patient is at risk for post-surgical complications such as bleeding, the nurse should first assess the patient before notifying the physician. • Auscultation of bowel sounds is not within the nursing assistant's scope of practice. Assessment is part of the nursing process and may not be delegated.
The nurse provides instructions to a patient with a gastric ulcer. The patient is treated with famotidine and a bland diet. The nurse should instruct the patient to perform which action?
Avoid aspirin and ibuprofen. Avoid caffeine intake. Discontinue smoking cigarettes. Explanation • Lifestyle factors may help alleviate symptoms during the recovery process for gastric ulcers. Prescribed treatment involves an antisecretory medication and bland diet. In addition, the patient should eat small, frequent meals, which helps reduce symptoms of bloating and pain associated with gastric secretion and ulceration. • The most common causes of peptic ulcer disease, which includes both gastric and duodenal ulcers, is H Pylori or the use of nonsteroidal anti-inflammatory medications such as ibuprofen or aspirin. • Aspirin and NSAIDs should be avoided due to possible gastric irritation and erosion. • Caffeine as well as nicotine increases gastric acid secretion and should be avoided. • Medication should not be discontinued without first consulting the physician.
A nurse is providing instructions to a patient with gastroesophageal reflux disease (GERD). The nurse should include which information?
Avoid spicy foods and alcohol. Avoid coffee and chocolate. Eat 4-6 small meals each day. Explanation • A patient with GERD should take steps to reduce gastric acid secretion and reflux. • The patient should eat frequent, smaller meals to avoid over distention and reflux. • Coffee, chocolate, spicy foods and alcohol can increase gastric acid secretion and decrease esophageal sphincter tone. • The head of the bed should be elevated to prevent reflux while sleeping. • Drinking a lot of water with meals should be avoided because this can cause the stomach to be over-distended and cause reflux.
A patient is admitted to the hospital with a diagnosis of acute hepatitis B. The nurse would expect a rise in which of the following serum labs?
Bilirubin AST ALT Explanation • The liver is responsible for modifying bilirubin to allow for excretion. With hepatitis, bilirubin cannot be excreted and instead builds up in the body. Hyperbilirubinemia causes jaundice. • ALT and AST are enzymes normally found circulating in the bloodstream and are associated with the liver, although not exclusively. If these enzyme levels are elevated, it can indicate inflammation or chronic damage to the liver. ALT and AST can be up to 10 times the upper limits of normal during an acute hepatitis B infection. • Creatinine is increased with kidney damage or failure. • Neutrophils are elevated during a bacterial infection. Hepatitis B is caused by a viral infection. • Thrombocytopenia occurs in liver disease and liver infection due to multiple factors including splenic sequestration of platelets in the case of portal hypertension, bone marrow suppression (which is where platelet stem cells are produced), antiviral treatment, reduced activity of thrombopoietin, and effects of generalized inflammatory processes.
A patient with hepatitis B asks the nurse how he contracted the disease. The nurse responds, knowing that hepatitis B is transmitted via:
Blood Explanation • Hepatitis A is transmitted by the fecal-oral route. It is often spread by contaminated food. • Hepatitis B is transmitted through body fluids such as blood, sexual fluids, and saliva. • Hepatitis C is transmitted through body fluids, primarily blood. • Hepatitis D is transmitted through body fluids such as blood, sexual fluids, and saliva. It causes infection only in the presence of Hepatitis B.
A patient with Crohn's disease is admitted to the hospital for a possible complication. The nurse knows that complications of Crohn's disease include which of the following?
Bowel obstruction Abdominal abscess Ileovesical fistula Explanation • Crohn's disease is an inflammatory bowel disease that is the most common cause of ileovesical fistulas, which are fistulas connecting the ileum to the urinary tract. • Other complications associated with Crohn's disease include colorectal cancer, bowel obstruction, ulceration, abscess, and thickening of the intestinal tract. • Sepsis, low sperm count, and intussusception are not commonly associated with Crohn's disease.
The nurse is caring for a patient in the advanced stages of cirrhosis. While making menu selections, the nurse should suggest increasing:
Carbohydrates. Explanation Protein intake was previously limited for all clients affected by cirrhosis because it added to the development of hepatic encephalopathy since ammonia is a byproduct of meat consumption and the liver is no longer able to clear that ammonia. Currently, protein is considered to be important to include in the diet of a client with cirrhosis to prevent muscle wasting. Clients with advanced cirrhosis, however, will be more likely to develop hepatic encephalopathy since the liver disease has progressed. This client should maintain normal and adequate amounts of protein, not increased amounts of protein. Decreased hepatic glycogen stores result in a starvation type metabolism. Increasing carbohydrates will ensure that the client stays in a "fed" state as opposed to a "fasting" state in which the body begins to consume alternate energy sources, such as muscle mass. A 50g carbohydrate snack at night, for example, improves nitrogen balance, glucose levels, and helps the client stay out of the fasting state, improving ability to maintain muscle mass. Fiber intake is important to prevent constipation. A low fat diet is typically recommended since obesity and high triglycerides can cause cirrhosis to advance more quickly.
A patient is being evaluated for abdominal pain. The nurse elicits Murphy's sign, or pain in the right upper quadrant along the costal margin. A positive Murphy's sign is indicative of:
Cholecystitis Explanation • A positive Murphy's sign is indicative of gall bladder inflammation. Cholecystitis is confirmed via ultrasound. • After the patient breathes out, the nurse firmly palpates below the right costal margin, mid-clavicular line. The patient is instructed to take a deep breath while the nurse deeply palpates. If the patient stops inhaling or winces, the test is positive.
A nurse is assessing a patient with cirrhosis. The nurse should know that which of the following would indicate late stage liver deterioration?
Confusion Flapping tremor of the hands Explanation • Hepatic deterioration, the later stages of cirrhosis, causes encephalopathy due to the increased levels of ammonia in the blood. This results in a diminished level of consciousness, confusion, flapping tremor of the hands (asterixis), and a sweet odor to the breath is often noted. • Weight loss and muscle weakness occur long before the later stages of cirrhosis. • Low urine output would be due to kidney deterioration.
A patient is seen in the clinic for ulcerative colitis, a form of inflammatory bowel disease. The nurse should anticipate including which of the following in the patient's care plan?
Corticosteroid medication Explanation • Corticosteroids are used to reduce inflammation associated with inflammatory bowel disease. This leads to decreased diarrhea, pain, and bleeding. • High fiber diets, milk, and lactulose will promote diarrhea.
The nurse is assessing a newly admitted patient and asks about family health history. Which of the following diseases has a familial basis?
Crohn's disease Explanation • Crohn's disease has a strong genetic component and often runs in families. • Crohn's disease is a type of inflammatory bowel disease that can affect any part of the digestive tract. It causes a wide range of symptoms including abdominal pain, diarrhea, vomiting, and weight loss. • Peritonitis and PUD are usually caused by infectious microbes. • Iron deficiency anemia is caused by an inadequate iron intake.
The nurse is instructing a patient before her scheduled upper GI endoscopy. The nurse should include which of the following?
Do not eat or drink for 8 hours before the procedure A sedative will be administered before the procedure Explanation • The patient should avoid eating and drinking for 8 hours before the endoscopy to ensure a clear view of the upper GI tract. Prior to the required fasting, a regular diet may be consumed. • Endoscopy is done under conscious sedation. • GI cleansers are for lower GI procedures. • A swallow and gag test must be performed before the patient can eat.
The nurse is assessing a patient who underwent a cholecystectomy 2 days ago. The nurse notes that the patient has no bowel sounds. What should the nurse do next?
Document the finding and continue assessing the patient's bowel function. Explanation • Bowel sounds are often absent 2-4 days after surgery due to manipulation of the bowel. This is an expected finding and should be documented. • The other answer choices are not necessary given that this is an expected finding.
A patient scheduled for surgery has questions regarding the care of his colostomy. Which of the following members of the health care team should be consulted?
Enterostomal nurse Explanation • The enterostomal nurse is trained and experienced in providing information and education to patients with a colostomy. The other options are incorrect because they lack the training and experience required for colostomy education.
The nurse is instructing a patient with gastroesophageal reflux disease (GERD) on potential complications if the disease is left untreated. The nurse includes which of the following?
Esophagitis Chronic cough Barrett's esophagus Explanation • GERD can cause many complications including esophagitis, esophageal strictures, esophageal cancer, and Barrett's esophagus. • Recurrent reflux can allow aspiration of small amounts of the gastric acids into the lungs, at times causing a reaction called pneumonitis (or aspiration pneumonia), but more commonly a chronic dry cough. • Barrett's esophagus refers to an abnormal change in the epithelium cells lining the esophagus. It is a premalignant condition that places the patient at a high risk for esophageal cancer. • Colorectal cancer, Crohn's disease, and hiatal hernias are not complications of GERD.
A nurse is caring for a patient who had an endoscopic retrograde cholangiopancreatography (ERCP) 2 hours ago. The nurse should alert the physician of which of the following signs and symptoms that suggest a complication from the procedure?
Fever Abdominal distention Abdominal pain Explanation • Major risks of ERCP include pancreatitis and perforation of the GI tract. Pain, distention, and fever are signs of these complications. • With any procedure performed during a hospital stay, there is a risk of developing hospital-acquired pneumonia. Shortness of breath is a common symptom of pneumonia, but there is a greater risk of pancreatitis and GI perforation. • The Absence of a gag reflex is expected after an ERCP due to the anesthetics used during the procedure. The gag reflex should return within a few hours after the procedure.
The nurse is monitoring a patient with diverticulitis for the presence of a bowel perforation. The nurse should be alert to which of the following?
Fever Tachycardia Abdominal guarding Board-like rigidity of the abdomen Explanation • Perforation causes a board-like rigidity of the abdomen, guarding of the abdomen, fever, chills, pallor, tachycardia, distention, and restlessness. • Perforation causes an inflammatory reaction in the peritoneal cavity called peritonitis. Sepsis can occur when the bowel contents leak into the peritoneum.
A 57-year-old is admitted to an inpatient unit due to Crohn's disease. Which of the following should not be in the care plan?
Fiber bar as a snack Milk with every meal Explanation • Crohn's disease is a type of inflammatory bowel disorder that can affect any part of the intestinal tract, including both the small and large intestine. • Foods high in fiber, such as whole grains, raw fruits and vegetables, and fiber bars may increase diarrhea. Milk and other lactose products may also increase diarrhea. • Corticosteroids and antidiarrheals should be used to reduce inflammation and diarrhea, respectively. • Avocados are a great source of nutrition for people with crohn's disease.
The nurse is caring for a patient with a small bowel obstruction. When planning the patient's care, the nurse should consider the immediate goal to be:
Fluid balance. Explanation • Patients often cannot tolerate oral fluids with a small bowel obstruction. The patient is at risk for fluid volume deficit and needs fluids to maintain balance. • Return of normal bowel function is important, but maintaining fluid balance is the immediate need.
The nurse is administering medications to a patient with a duodenal ulcer. The patient asks about his medications and how they treat his disease. The nurse explains that duodenal ulcers are predominately caused by:
Helicobacter pylori. Explanation • Up to 90% of duodenal ulcers are caused by the bacteria Helicobacter pylori (H. pylori). Treatment consists of 1 or 2 antibiotics, a proton pump inhibitor, and bismuth. • Stress, NSAID use, and alcohol can lead to gastric, not duodenal ulcers.
A nurse is assessing a patient suspected of an upper GI bleed. Which test should be used first to evaluate the patient's GI bleed?
Hemoglobin and hematocrit Explanation • Hemoglobin and hematocrit are used to evaluate the severity of blood loss. This test is quick and inexpensive. Therefore, it is often the first test performed. • Endoscopy should be done after other assessment data has confirmed the likelihood of a GI bleed. Endoscopy will directly visualize the source of bleeding and stop it. • A WBC count and PT/INR can be done to evaluate the patient's infection and coagulation status.
A patient with hepatitis is admitted to the hospital. The physician believes he contracted the disease from contaminated food. Which of the following is most likely the diagnosis?
Hepatitis A Explanation • Hepatitis A is transmitted by the fecal-oral route. It is often spread by contaminated food. • Hepatitis B is transmitted through body fluids such as blood, sexual fluids, and saliva. • Hepatitis C is transmitted through body fluids, primarily blood. • Hepatitis D is transmitted through body fluids such as blood, sexual fluids, and saliva. It causes infection only in the presence of Hepatitis B.
A patient with diverticulosis is being instructed on disease management. The nurse instructs the patient to consume a diet including which of the following?
High in water intake High in fiber Explanation • Constipation should be prevented for a patient with diverticulosis by increasing fiber and water intake. The patient may also be prescribed bulk laxatives. • Nuts and almonds are high in fat and may contribute to complications as pieces of nuts may lodge in the diverticula. • A low-roughage diet is one low in fiber and not recommended unless having an acute attack of diverticulitis. However, this patient is not having an acute attack of diverticulitis. • A diet low in vegetables will not provide the patient with enough nutrients or fiber.
A 53-year-old male patient is scheduled to undergo an endoscopic retrograde cholangiopancreatography (ERCP). The nurse performs an assessment on the patient prior to the procedure. Which of the following health background information from the patient should alert the nurse?
History of allergic reaction to contrast dye Explanation • ERCP uses contrast dye to better visualize pancreatic and biliary ducts. • A history of a prior allergic reaction to contrast dye is associated with an increased likelihood of a subsequent reaction. • In the past, a history of an allergic reaction or sensitivity to seafood/shellfish allergy was thought to indicate an increased risk of allergy to contrast/dye containing iodine. This has proven to be untrue and shellfish allergy is no longer considered an absolute contraindication to the administration of IV contrast material. • Some patients can be sensitive to iodine-binders used in Povidone but there is no cross-sensitivity between this and iodinated contrast materials. • Familial history of hypertension is not relevant for the procedure, BP and PR are of normal values, and 8-10 glasses of water intake is also normal and acceptable.
A patient with pancreatitis is at risk for developing a paralytic ileus. Which of the following assessment data indicates this complication?
Inability to pass flatus Explanation • Paralytic ileus is the most common form of nonmechanical obstruction and often presents with the inability to pass flatus. • Nausea may be present with an obstruction, but in this case, it is most likely due to pancreatitis. • Pain from an ileus is usually dull and generalized. • A firm mass at the right costal margin is indicative of cirrhosis.
A patient with chronic hepatitis is admitted to the hospital due to his declining status. The nurse assesses the patient and will most likely note which of the following?
Increased bleeding tendencies Fatigue Peripheral edema Explanation • Chronic hepatitis will eventually cause extensive damage to the liver and nutritional deficiencies. • The patient will often have muscle wasting, weakness, fatigue, increased bleeding, decreased body hair, and peripheral edema. • Liver dysfunction leads to low serum albumin, which causes low oncotic pressure, contributing to edema. • Jaundice (yellow skin and conjunctiva) may also be present due to a buildup of bilirubin.
The nurse is preparing a care plan for a patient with ascites related to cirrhosis. Which of the following nursing diagnoses should take priority?
Ineffective breathing pattern Explanation • Due to the accumulation of fluid in the abdomen, pressure is placed on the diaphragm and can interfere with breathing. This can lead to pneumonia or atelectasis. • The remaining nursing diagnoses are important but do not take priority.
A nurse is performing an abdominal assessment on a healthy 45-year-old. The nurse should perform the assessment in which order?
Inspect, auscultate, percuss and palpate Explanation • This sequence allows accurate assessment of bowel sounds and delays more uncomfortable maneuvers until the end. • Palpating the abdomen before auscultation temporarily increases bowel sounds.
A patient had a colon resection surgery 2 days ago. The patient states that he has not had a bowel movement yet but is passing gas. What should the nurse do?
Instruct the patient to ambulate and be active Explanation • Ambulation stimulates peristalsis and can improve bowel function and regularity. • Notifying the physician is not necessary because the patient shows signs of bowel function. • Administering medication or an enema and advancing the patient's diet are not indicated at this time unless ordered by the physician
The nurse is providing discharge instructions to a patient with a nasogastric (NG) tube. If the NG tube becomes clogged, the nurse should instruct the patient to:
Irrigate the NG with bicarbonate as prescribed. Explanation • Bicarbonate is effective and inexpensive for irrigating a clogged NG tube. • Advancing or withdrawing the tube is inappropriate because the NG tube is supposed to be in the stomach. • Aspirating with a syringe is usually ineffective.
A patient suspected of diverticulitis is admitted to the hospital for evaluation and treatment. The nurse explains to a student nurse that the classic triad of signs and symptoms are:
LLQ pain, fever, leukocytosis. Explanation • The classic symptoms of diverticulitis are fever, LLQ pain, and leukocytosis. • Other symptoms include constipation or diarrhea, occult blood in the stool, nausea, and cramping.
The nurse is assessing a patient with a 4-day history of diarrhea. The nurse assesses the patient for which of the following?
Lethargy Tachycardia Skin tenting Explanation • Tenting of the skin, although not specific, occurs early on due to dehydration caused by prolonged diarrhea or vomiting. • The nurse should also assess for other signs of dehydration such as weight loss, sunken eyes, hypotension, tachycardia, lethargy, and headache.
A client admitted to the ICU due to unresponsiveness is diagnosed with cerebrovascular accident (CVA) and started on nasogastric tube feedings. As the nurse checks tube placement to prepare for the next feeding, which of the following should be performed for gastric residual greater than 100mL?
Maintaining the client in a semi-Fowler's position in bed Reinstilling the gastric contents into the stomach per facility policy Withholding the feed, and rechecking residuals in 1 hour Explanation • Ensuring the patient is in a semi-Fowler's position enhances the gravitational flow of the solution, and lowers risk for aspiration of gastric contents into the lungs. • The entire gastric contents are removed and measured before every intermittent feeding (or every 8 hours for continuous feedings) to monitor for delayed gastric emptying. Acceptable residual amounts are according to the provider's guideline or institution policy; however, typically residuals should not be greater than one-half the amount of the last feeding. • If there is more than 100ml gastric residual, the feeding should be withheld and the residual reassessed after an hour. The provider should be notified of suspected delayed gastric emptying AFTER the nurse has re-evaluated residuals. • Any measured residual fluid should be documented and replaced into the patient's stomach to prevent fluid, electrolyte, and nutrient loss. • 4-6 hourly removal and wasting of the contents could disturb the client's electrolyte balance. • Check tube placement every 8 hours for continuous feedings according to facility policy, and prior to each intermittent feeding or medication administration via tube. The pH of the removed gastric content is tested first, before the total gastric residual is removed, in order to confirm placement of the tube. The pH of gastric contents should be less than 5.5 and be green, tan, or white. If the patient takes an acid-inhibiting medication, less than 6.0 is normal. The fluid in the small intestines is yellowish or brown-green and thicker, and the pH is 6 or higher. If the pH is over 7, it indicates respiratory fluid, and an x-ray would be needed to check placement.
An 82-year-old patient is having trouble maintaining regular bowel movements. The nurse is providing instruction and tells the patient to avoid:
Mineral oil. Explanation • Older adults should not use mineral oil due to the risk of decreased absorption of fat-soluble vitamins. • Fiber, water, and exercise should be encouraged to help maintain regular bowel movements. • Bulk-forming laxatives are the drug of choice for long-term management of constipation, especially in older adults, due to the low side effect profile.
The nurse is assessing a patient diagnosed with acute pancreatitis. Which of the following assessment findings is consistent with this diagnosis?
Nausea/vomiting Upper epigastric pain and back pain Elevated temperature Explanation • Common symptoms of acute pancreatitis include upper epigastric pain that bores through the body to the back, nausea, vomiting, weight loss, and an elevated temperature. • Hypertension is not associated with pancreatitis, although blood pressure may become elevated in response to pain. • RLQ pain is usually associated with appendicitis, not pancreatitis.
A patient is being examined for a suspected peptic ulcer. The nurse knows that what symptom indicates a duodenal ulcer rather than a gastric ulcer?
Pain is relieved by meals Explanation • With duodenal ulcers, pain is relieved during meal time due to the closure of the pyloric sphincter. Pain will manifest about 2-3 hours after a meal when the pylorus opens and releases gastric contents into the small intestine. • With gastric ulcers, pain is intensified with meals due to the release of gastric acid. • Hematemesis and nausea can occur with both types of ulcers.
The nurse is providing ostomy care for a patient after a colectomy. The patient is complaining of the foul odor coming from the ostomy. The nurse instructs the patient to consume more odor eliminating foods, such as:
Parsley. Explanation • Patients with an ostomy can consume yogurt, parsley, buttermilk, and cranberry juice to help eliminate fecal odor. • Foods that will increase fecal odor include beans, cucumbers, radishes, alcohol, asparagus, cabbage, eggs, and fish.
A nurse is caring for a patient who is scheduled to have a barium enema the following day to check for the presence of colon polyps. When the nurse enters the patient's room during rounds, which of the following should alert the nurse?
Patient is drinking milk before bedtime. Explanation The patient should be on a clear liquid diet for 2 days before the procedure to reduce stool volume. • The other choices are the correct preparation before a barium enema. (Patient had a cup of chicken broth soup for dinner. Patient reported having two bowel movements after taking the laxative. Patient reported to have taken 4 glasses of water for the last 8 hours.)
The nurse is assessing a hospitalized patient after complaints of sudden abdominal pain. Which of the following abdominal assessment findings should be reported to the physician immediately?
Pulsation between the pubis and umbilicus Explanation • Pulsation between the pubis and umbilicus indicates an abdominal aortic aneurysm. This is a medical emergency and should be reported to the physician immediately. • 20 bowel sounds per minute is a normal finding. • LLQ firm to palpation may be due to feces in the colon. • Nausea does not have to be reported to the physician.
A patient is seen in the clinic for symptoms consistent with gastroesophageal reflux disease. The nurse should expect which common symptoms?
Sore throat Regurgitation Nausea Epigastric pain Explanation • The most common symptoms of GERD include heartburn (sometimes described as chest pain), regurgitation, trouble swallowing, sore throat, and nausea. GERD pain is sometimes described as epigastric pain (not abdominal pain). It does not cause bloody stool.
The nurse is caring for a patient with hepatic encephalopathy. When advising him on menu options, the nurse tells the patient to avoid:
Steak. Explanation • Hepatic encephalopathy occurs when liver failure causes the accumulation of toxins, such as ammonia. This causes confusion, altered level of consciousness, and coma. • The patient is unable to convert ammonia to urea. Therefore, the patient should avoid foods high in protein.
A patient with peptic ulcers is admitted to the hospital for a suspected perforation. While assessing the patient, the nurse would expect which common symptom of this complication?
Sudden, severe pain in the abdomen Explanation • The most indicative symptom of a perforation is abdominal pain that is severe with a sudden onset. • Bloody stools indicate GI bleeding, but it is not indicative of perforation. • Bowel sounds may be absent, but this varies. • Pulses are often weak and rapid when a perforation occurs.
Which assessment finding would indicate that a patient's ascites is improving?
The amount of ankle edema is now 1+ pitting and 12 hours ago was reported as 3+ pitting Patient reports easier breathing Abdominal girth decreases Urine output increases Explanation • Increased urine output indicates that the ascitic fluid is being absorbed into the circulation and then excreted. • Peripheral edema should decrease as ascites resolves. • Ascites, the accumulation of fluid in the peritoneal cavity, increases abdominal girth and can also inhibit the movement of the diaphragm, resulting in difficulty breathing. As it resolves, breathing eases. • Abdominal skin should become less shiny. • Lower fluid volume should cause the pulse rate to slow, not to increase.
The nurse assesses a patient with a small bowel obstruction and an NG tube set to intermittent wall suction. The patient has been reluctant to ambulate and is complaining of continued pain and nausea. The nurse determines a nursing diagnosis of acute pain with a goal to reach the patient's acceptable pain level of 4 out of 10 by the end of shift. Which is the most appropriate intervention to meet that goal?
The patient will ambulate 100 feet with assistance every two hours and will receive analgesia as ordered. Explanation •A combination of ambulation and analgesia is the most effective method to relieve the pain from a bowel obstruction. •Immobility decreases peristalsis. In a patient with a bowel obstruction due to adhesions, it is important to encourage activity to stimulate peristalsis. This can help relieve pain by resolving the obstruction. Continued immobility will lengthen the recovery time, increase pain, and potentially result in the patient needing surgical release of the obstruction. •The other choices are incorrect because immobility and increasing the narcotic analgesia will decrease peristalsis and increase the patient's pain.
A home health nurse is examining a patient with a hiatal hernia. Which of the following would the nurse note as a classic sign of hiatal hernias?
There is no classic sign or symptom. Explanation • Hiatal hernias often cause vague symptoms that can resemble the symptoms of many disorders. Dull chest pain, shortness of breath, reflux, heartburn, and heart palpitations are all symptoms of hiatal hernias, but can be present in a number of diseases. • A hiatal hernia is when a portion of the stomach herniates through the diaphragm, into the thorax.
A patient is being cared for by a home-health nurse. The patient has jaundice and is complaining of pruritus. Which of the following interventions can the patient implement to reduce pruritus?
Use tepid water for bathing Maintain a cool house temperature Explanation • To reduce pruritus related to bile salt accumulation, the patient should keep his house cool, wear loose clothing, use tepid water for bathing, use mild soaps, and take antihistamines. • Hot water, alkaline soaps, and tight clothing can irritate the skin, making pruritus worse.
A patient is seen in the clinic for a follow-up related to chronic gastritis. The nurse should be alert for which vitamin deficiency?
Vitamin B12 Explanation Chronic gastritis leads to deterioration of the lining of the stomach, leading to the inability to secrete intrinsic factor. Intrinsic factor is required for the absorption of vitamin B12.
A 21-year-old female is admitted to the hospital with intense right lower quadrant pain. Serum labs are drawn and reviewed by the nurse. Which of the following should be reported to the physician?
WBC 21,000 cells/mL Explanation • Normal WBC count is 4,000-10,000 cells/mm³. • Right lower quadrant pain and an elevated WBC count indicates appendicitis and possible rupture. The physician should be notified immediately to begin antibiotic therapy and treatment. • Normal hemoglobin is 14-18 g/dL for males and 12-16 g/dL for females. The patient's hemoglobin is low, but not critically low. • Normal HCO3 (Bicarbonate) is 22-28 mEq/L. • Normal lactic acid (lactate) is 0.5-2.2 mmol/L. • Hemoglobin is low, but should be compared to the previous result to identify changes.
A nurse received an order to initiate early ambulation with a patient post appendectomy. The nurse recognizes this activity to be helpful in preventing possible complications associated with prolonged bed rest. To assist the patient to start walking after surgery, the nurse will:
With 15 minutes intervals, the nurse begins to position patient into high-Fowler's, then instructs her to dangle her feet at the bedside. After this, she assists her in moving from the bed to the chair and then, she walks with her around the room. Explanation • Early walking after surgery prevents the development of complications. The nurse facilitates proper ambulation when she instructs the patient to perform leg exercises while in bed and positions her to high-Fowlers. • Then, the patient is instructed to dangle her feet at the bedside. The patient may feel dizzy, nauseated, or faint so it must be performed slowly and with long intervals in between. Then, the patient is moved from the bed to the chair and should be assisted to walk around the room. • Other options show inappropriate ambulation because the procedure was done too quickly and non-systematic.
A patient is being treated for choledocholithiasis, a gallstone lodged in the common bile duct. The nurse expects to note which assessment finding?
Yellow sclera Explanation • Obstruction of the common bile duct inhibits liver and gall bladder secretion. This leads to jaundice and liver damage. • Tarry stools and constipation are not associated with this disease. • Nausea may be present.
A patient at risk for colorectal cancer is receiving education about lifestyle choices. The nurse should emphasize which of the following modifiable risk factors to colorectal cancer?
diet Explanation • An important modifiable risk factor is diet. Dietary recommendations include consuming less saturated fat and salt and eating a variety of colorful fruits and vegetables. • Age, ethnicity and family history are not modifiable risk factors. Greater than 75% of colon cancer occurs in people with little or no genetic risk.
The nurse is caring for a patient who underwent a gastric bypass surgery. Knowing that this patient is at risk for dumping syndrome, the nurse assesses the patient for which of the following?
dizziness Diarrhea Syncope Palpitations Explanation • Dumping syndrome is when ingested foods bypass the stomach too quickly and enter the intestine undigested. This expands the duodenum too quickly and causes rapid water entry into the intestine as well as excessive insulin release from the pancreas. • Symptoms of dumping syndrome include dizziness, hypotension, syncope, sweating, tachycardia, palpitations, nausea, and diarrhea.
The nurse is caring for a patient with a paralytic ileus. While assessing the patient, the nurse would expect bowel sounds to be:
hypoactive Explanation • With a paralytic ileus, there is a decrease in bowel motility, resulting in hypoactive or absent bowel sounds. • Hyperactive bowel sounds may indicate a mechanical obstruction.
A patient with cholecystitis is receiving nutritional counseling. The nurse should instruct the patient to:
limit fatty foods Explanation • Fat stimulates the release of bile from the gall bladder. During cholecystitis, this will irritate the gallbladder and cause pain. • Carbohydrate and protein intake do not affect the gallbladder.
A patient recently diagnosed with celiac disease wants to know more about what foods he should avoid. Which of the following should be included in the discharge instructions as a food to avoid?
rye bread Explanation • Rye bread contains gluten, which must be avoided in celiac disease. • The other choices are common food allergies but do not relate to celiac disease. • Celiac disease is an autoimmune disorder of the small intestine that causes chronic diarrhea, failure to thrive, and fatigue. The cause is genetic predisposition.
The nurse is assessing a patient suspected of having a duodenal ulcer. The patient admits to having a family history of this disease. The nurse knows that another known risk factor for duodenal ulcers is which of the following blood types?
type O Explanation • People with blood type O develop duodenal ulcers more frequently than the standard population, suggesting a familial basis. Type A, B, and AB are not linked to duodenal ulcers.
The nurse is assessing a patient with advanced cirrhosis. The nurse should be alert for which sign of hepatic deterioration?
weight gain Altered level of consciousness Confusion Explanation • This scenario describes hepatic encephalopathy. This causes central nervous system toxicity, leading to altered level of consciousness, confusion, and coma. • Weight gain may also be seen due to third spacing, associated with lower albumin levels secondary to liver damage. • Weight loss and anorexia occur earlier in the disease process.
