Gastrointestinal System (Med-Surg)

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?

"Before I start the procedure, I will measure the residual volume." Rationale: Measuring the residual volume establishes the absorption amount of the previous feeding. If a residual exceeds the parameter identified by the health care provider or is over 200 mL, a feeding may be held. This safety measure prevents adding excess feeding solution that may lead to abdominal distention, nausea, vomiting, and aspiration. Clean, not sterile, gloves are necessary to protect the client from contamination with gastric secretions. The client obtains and reports weekly or monthly weights, depending on the client's condition and clinical goals. If the tube becomes clogged, the client may instill 30 mL of a carbonated beverage; this action is not used routinely.

The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes which statement?

"I should wash my hands frequently." Rationale: Hepatitis A microorganisms are transmitted via the anal-oral route; hand washing, particularly after toileting, is the most important precaution. The response "I should launder my clothes separately" will not deter the spread of the virus; hand washing is necessary. Putting used tissue in the garbage is important, but hand washing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

During a health symposium the nurse teaches the group how to prevent food poisoning. Which statement by one of the participants indicates the teaching is understood?

"Meats and cream-based foods need to be refrigerated." Rationale: A cold environment limits growth of microorganisms. All food should be refrigerated before and after it is cooked to limit the growth of microorganisms. Stuffing and then refrigerating poultry promotes the growth of microorganisms because the stuffing will still be warm for a period before the refrigerator's cold environment cools the center of the bird. It is advocated that poultry not be stuffed. If it is stuffed, it should be done immediately before cooking. Letting cooked foods cool before refrigeration promotes the growth of microorganisms because microorganisms thrive in warm, moist environments.

When admitting an older client, the stool specimen confirmed a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse inquires about potentially assigning Room 2010, Bed B, the same isolation room as another client (2010, Bed A) who has MRSA. Which response would the nurse receive?

"Placing clients with the same infection in 1 room is safe." Rationale: There is no need to separate 1 client with MRSA from another client with the same infection. MRSA infections are highly contagious. MRSA infections are resistant to most antibiotics, especially methicillin. Clients with the same infection can remain in the same room; contact precautions are necessary to protect visitors and staff members.

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, which would the nurse emphasize?

For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful. Rationale: Medical treatment is directed toward reducing motility of the inflamed bowel, restoring nutrition, and preventing and treating infection; surgery is used selectively for those who are acutely ill or have excessive exacerbations. Stating that medical treatment for colitis is curative and that surgery is not required is untrue; medical treatment is symptomatic, not curative. It usually is performed as a last resort. Although there is an emotional component, the physiological adaptations determine whether surgery is necessary.

After numerous diagnostic tests, a client with jaundice receives the diagnosis of pancreatic cancer. Which rational explains the cause of the client's jaundice?

Obstruction of the common bile duct by the pancreatic neoplasm Rationale: The common bile duct passes through the head of the pancreas; the neoplasm often constricts or obstructs the duct, causing jaundice. Necrosis of the pancreatic parenchyma caused by the neoplasm will not cause jaundice. Excessive serum bilirubin caused by red blood cell destruction is the prehepatic cause of jaundice. Impaired liver function, resulting in incomplete bilirubin metabolism, is a hepatic cause of jaundice.

A client, readmitted for exacerbation of ulcerative colitis, is weak, thin, and irritable. The client states, "I am now ready for the surgery to create an ileostomy." Which nursing intervention best meets the client's needs at this time?

Parenterally replace the client's fluids and electrolytes. Rationale: When a client has an ulcerative colitis exacerbation, the client may have more than 10 stools per day, and the stools are bloody and full of mucus. The client can become dehydrated and lose vital electrolytes. Parenterally replacing fluids and electrolytes is a life-saving strategy; replacement occurs before performing the surgery to stabilize the client. Helping the client regain former body weight is not the priority at this time. The client is neither physically nor cognitively ready to learn the psychomotor skill of how to manage an ileostomy. The client is not demonstrating a readiness for contact with other persons with ileostomies at this time.

The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. One, some, or all responses may be correct.

Rebound Tenderness Diminished Bowel Sounds Rigid, Boardlike Abdomen Rationale: Classic signs of peritonitis include abdominal rebound tenderness, diminished or absent bowel sounds, and a rigid, boardlike abdomen. The client will experience constipation, not diarrhea. The heart rate will be tachycardic.

The nurse is preparing to insert a nasogastric (NG) tube for a client to allow continuous suction. Which tube would the nurse select?

Salem sump Rationale: A Salem sump tube has a vent that prevents the suction from pulling at the gastrointestinal mucosa and should be used for clients requiring continuous suction. A Levin tube does not have a vent and should be used strictly for intermittent suction. A Dobhoff is a nasointestinal tube used for feeding, not suction. A gastrostomy tube is surgically placed for feeding.

A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. Which explanation would the nurse give?

Stores and concentrates bile Rationale: The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.

A client who had an abdominoperineal resection and colostomy refuses to allow any family members to see the incision or stoma. The client is noncompliant with most of the dietary recommendations. Which response does the nurse conclude that the client is experiencing?

The client is experiencing denial; the client is having difficulty accepting reality. Rationale: As long as no one else confirms the presence of the stoma and the client does not adhere to a prescribed regimen, the client's denial is supported. There is no evidence to document that reaction formation is being used. There are no data to support the conclusion that the client has an inability to function sexually. There is no evidence that suicidal thoughts are present or will be acted upon.

Which pain-related clinical manifestation would the nurse expect in a client who had received a diagnosis of a peptic ulcer?

The pain occurs 1 to 2 hours after having a meal. Rationale: Pain occurs after the stomach empties; eating stimulates gastric secretions, which act on the gastric mucosa of an empty stomach, causing gnawing pain. Vomiting temporarily alleviates pain because acid secretions are removed. There is no intolerance of fats, and eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; however, it only radiates to the abdomen if the ulcer has perforated.

A client expresses a complete lack of interest in food. How would the nurse document this finding in the client's medical record?

Anorexia

A client had a colon resection and formation of a colostomy 2 days ago. Which color indicates to the nurse that the stoma is viable?

Brick Red Rationale: A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

A client is admitted via the emergency department with a tentative diagnosis of diverticulitis. The nurse anticipates that which test will be prescribed?

Computed tomography (CT) scan Rationale: A CT scan with contrast is the test of choice for diverticulitis because it effectively reflects the involved colon. A gastroscopy assesses the upper, not lower, gastrointestinal tract. Colonoscopy is contraindicated because of the possibility of perforation and peritonitis. Barium enema is contraindicated because of the possibility of perforation and peritonitis.

When assessing a client's abdomen, the nurse palpates directly above the umbilicus. This location is known as which area?

Epigastric Area Rationale: The stomach is located within the sternal angle, known as the epigastric area. The iliac area is in the area of the iliac bones. The hypogastric area is the lowest middle abdominal area. The suprasternal area is the area above the sternum.

A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors?

Individuals who are obese are more prone to this condition than those who are thin. Rationale: Cholelithiasis occurs more frequently in individuals who are obese and have hyperlipidemia. Women are more likely to develop cholelithiasis. Middle-aged people, usually over 40 years, are more likely to develop this condition than younger people; aging increases risk. People who have sedentary lifestyles are more likely to develop this condition than those who are active.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, which action would the nurse take?

Instruct the client to empty the bladder. Rationale: Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. Shaving the client's abdomen and medicating the client for pain are not necessary. Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

A client who previously resided in a foreign country has a chronic vitamin A deficiency. Which information about vitamin A would the nurse consider when assessing the client?

It is a necessary element of rhodopsin, which controls responses to light and dark environments. Rationale: Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremor. Based upon this assessment, which prescribed diet would the nurse anticipate?

Moderate Protein Rationale: Because the liver is unable to detoxify ammonia to urea and the client is experiencing clinical manifestations leading to an impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no-protein restrictions are not required because the client needs protein for healing. The hepatic encephalopathy diagnosis contradicts high-protein intake because protein breaks down into ammonia.

The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client?

Permanent sigmoid colostomy Rationale: When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon (abdominoperineal resection), a permanent colostomy is formed. The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. Temporary double-barrel colostomy is performed to allow a segment of colon to heal; intestinal continuity is restored eventually. Temporary transverse loop colostomy commonly is performed for inflammation of the colon when intestinal continuity eventually can be restored.

A client with esophageal varices experiences severe hematemesis, and a Sengstaken-Blakemore tube is inserted. Which design and purpose does the tube have?

Triple-lumen; for esophageal compression

A client is admitted to the hospital for a laparoscopic cholecystectomy. Which item would the nurse encourage the client to add to the diet to help normalize bowel function after surgery?

Whole bran Rationale: Whole bran provides bulk that promotes intestinal motility and regular bowel movements. Vitamins are not related to normalizing bowel function. Cod liver oil is not related to regulating bowel function. Amino acids are not related to regulating bowel function.

A client has a colostomy after surgery for cancer of the colon. Which postoperative nursing intervention maximizes skin integrity?

Apply stoma adhesive around the stoma and then attach the appliance. rationale: Stoma adhesive protects the skin and helps keep the appliance attached to the skin. The appliance should be emptied when it is one-third to one-half full. Allowing one-half inch between the stoma and the appliance is too much space; the enzymes in feces can erode the skin. Initially the nurse should change the appliance; self-care usually is instituted more gradually, depending on the client's physical and emotional response to the surgery.

The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step?

Assess barriers to learning colostomy care. Rationale: Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Beginning with simple written instructions concerning the care is premature. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. Waiting until the client has accepted the change in body image may be an unrealistic expectation; the client may never accept the change but must learn to manage care.

The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?

Bowel Obstruction Rationale: Causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis. Gastritis and hiatal hernias do cause gastrointestinal discomfort, but not peritonitis. Inflammation of the diverticular pockets, diverticulitis, is a cause of peritonitis. Diverticulosis is not an active inflammatory process.

A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function?

Cellular membrane structure Rationale: Cholesterol is an essential structural and functional component of most cellular membranes. The fact that it is associated with atherosclerotic plaques does not detract from its essential functions. Cholesterol is not necessary for blood clotting; calcium and vitamin K are. Cholesterol is not essential for bone formation; calcium, phosphorus, and calciferol are. Cholesterol is not involved in muscle contraction; potassium, sodium, and calcium are.

Which information would the nurse provide a client with a new colostomy about managing the appliance?

Cut opening 1/8- to 1/16-inch larger than stoma. Rationale: The first 6 to 8 weeks after surgery as inflammation subsides, the stoma will shrink in size. Therefore it is important to measure the stoma once a week and cut the opening 1/8- to 1/16-inch larger than the stoma so the wafer does not cut into the stoma. Antifungal cream or powder is used for fungal rashes. Soap should not be used on the peristomal area to prevent drying, which can lead to infection.

Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct.

Fever Diarrhea Abdominal Cramps Rationale: The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Hemoptysis (coughing up blood from the respiratory tract) is not a related sign.

A client with a body mass index (BMI) of 35 verbalizes the need to lose weight. The nurse encourages the client to lose weight safely by making which dietary change?

Decrease portion size and fat intake. Rationale: The most effective and safest method for achieving weight loss is to decrease caloric intake. This is best accomplished by maintaining a balance of nutrients while decreasing portion size and fat intake. A gram of fat is 9 calories, whereas a gram of protein and a gram of carbohydrate are 4 calories each. Increasing protein intake can increase fat intake because animal protein also contains fat. Although decreasing carbohydrate and fat intake will promote weight loss, the diet may result in an imbalance of nutrients, which may jeopardize the client's health. Fruits are important in any diet, and if a balance of nutrients is to be maintained, fruit intake may need to be increased or decreased depending on the client's eating habits. Water intake should not be limited in a weight loss diet.

Which assessment parameter is used to determine the severity of blood loss in a client with an upper gastrointestinal (UGI) bleed? Select all that apply. One, some, or all responses may be correct.

Hematocrit Hemoglobin Platelet count Oxygen saturation Blood urea nitrogen (BUN) Rationale: A decrease in hematocrit and hemoglobin would typically occur within 4 to 6 hours of the start of a UGI bleed. The client's platelet count would rise in response to the bleed as the body attempts to stop the bleeding. Oxygen saturation levels would decrease when the client has lost a large quantity of blood. BUN levels would also be elevated in a UGI bleed.

A client describes abdominal discomfort after ingestion of milk. Which enzyme, as a result of a genetic deficiency, would the nurse consider to be the cause of the client's discomfort?

Lactase Rationale: Milk and milk products are not tolerated well because they contain lactose, a sugar that is converted to galactose by lactase. Sucrase assists in the digestion of sucrose, which is not a milk sugar. Maltase assists in the digestion of maltose, which is not a milk sugar. Amylase assists in the digestion of starch, which is not a milk sugar.

Which finding would the nurse document as normal for a second, postabdominoperineal resection stoma?

Moist, red, and raised above the skin surface Rationale: The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; elevation of the stoma beyond the skin surface usually occurs to allow drainage to go into the appliance rather than onto the skin. The stoma should be moist, not dry. Pale pink may indicate limited circulation to the stoma. Although some stomas can be flush with the skin, a raised stoma is more common. Although the stoma should be moist, a skin-colored stoma indicates limited circulation to the stoma. A purple color indicates compromised circulation.

On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform first?

Obtain the client's vital signs. Rationale: Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis; vital signs provide supporting data. The nurse assists the client to ambulate if pain was the result of flatulence; however, rigidity is associated with bleeding or peritonitis, and the nurse needs additional data. An analgesic may mask the symptoms, thereby delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to the symptoms presented.

The nurse identifies which weight category as reflective of a client's body mass index (BMI) of 25.5 kg/m2?

Overweight Rationale: A BMI between 25 and 29.9 kg/m2 places the client in the overweight category. A BMI of 30 kg/m2 is considered obese. A normal BMI is between 18.5 kg/m2 and 24.9 kg/m2. A BMI below 18.5 kg/m2 is considered underweight.

Which dietary selections made by the client indicate understanding of previously taught dietary principles associated with having viral hepatitis?

Salad, sliced chicken sandwich, gelatin dessert Rationale: The viral hepatitis diet should be high in carbohydrates, with moderate protein and fat content. A salad, chicken, and gelatin meal is the best choice. Turkey salad, French fries, and sherbet are too high in fat. Cottage cheese, mixed fruit salad, and a milkshake are dairy products and may cause lactose intolerance; the hepatitis virus injures the intestinal mucosa and reduces the client's ability to metabolize lactose. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.

Which finding is an indication of ulcer perforation in a client with peptic ulcer disease (PUD)? Select all that apply. One, some, or all responses may be correct.

Tachycardia Hypotension Rigid abdomen Nausea and vomiting Back and shoulder pain Rationale: Perforation of an ulcer can cause tachycardia and hypotension (both caused by fluid volume shifts from the vascular compartment to the abdominal cavity). A client with a perforated ulcer would have a hard, rigid abdomen (caused by tensed muscles) and nausea and vomiting. Back and shoulder pain can occur as a result of irritation of the phrenic nerve.