PassPoint - Gastrointestinal Disorders
An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?
"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently."
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation."
The nurse is instructing the client about health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions?
"I will avoid lying down after a meal."
A client with constipation takes psyllium granules as 1 rounded teaspoon mixed in fruit juice 3 times daily. Which of the following statements by the client indicates that further teaching is required?
"I will need to take the medication for 4 weeks."
Which statement, made by a client with a hiatal hernia, indicates that the client understands the treatment plan?
"I will sit in a chair for several hours after I eat."
Which statement indicates that the client with hepatitis B has understood the nurse's discharge teaching?
"I won't drink alcohol for at least 1 year."
A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes?
Acetaminophen
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
Acute pain related to biliary spasms
The nurse is caring for an adult who had a gastric resection. At 1700 the following day, the client requests pain medication. The client's health care provider has prescribed morphine 5 mg intravenously every 3 to 4 hours. The nurse reviews the client's progress notes (view the chart). What should the nurse do next?
Administer the pain medication as requested.
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain described as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the NG tube.cramping
A child with Hirschsprung disease is to be discharged 1 or 2 days after a colostomy takedown surgery. After teaching the infant's parents about the overall effects of their infant's surgery, the nurse determines that the teaching has been effective when the parents make which statement?
Assess the client for signs of peritonitis.
The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. What information should the nurse give the client?
Avoid lifting items weighing more than 5 lb (2.3 kg).
The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first?
Check the function of the suction equipment.
At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should perform which action next?
Evaluate the tube for patency.
A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take?
Increase fluids.
A nurse is assisting the health care provider (HCP) with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?
Instruct the client to take a deep breath and hold it.
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?
Localized warmth is felt over the incisional area.
A client is admitted to the hospital with a diagnosis of cholecystitis. The client has severe abdominal pain and nausea and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time?
Manage the pain.
A client with a well-managed ileostomy has the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do?
Notify the health care provider (HCP).
A client with a peptic ulcer reports epigastric pain that frequently causes the client to wake up during the night. The nurse should instruct the client to take which action(s)? Select all that apply.
Obtain adequate rest to reduce stimulation. Eat small, frequent meals throughout the day. Take all medications on time as ordered. Sit up for 1 hour when awakened at night.
An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain before surgery?
Place the client in semi-Fowler position with the knee gatch raised.
The nurse is reviewing the chart information for a client with increased ascites. The data include temperature 98.9°F (37.2°C); heart rate 118 bpm; shallow respirations 26 breaths/min; blood pressure 128/76 mm Hg; and percutaneous oxygen saturation (SpO2) 89% on room air. What should the nurse do first?
Raise the head of the bed.
The client is scheduled to have an upper gastrointestinal tract series of X-rays. Following the X-rays, what should the nurse instruct the client to do?
Take a laxative.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener such as docusate sodium daily.
The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication?
Take it with a full glass (240 mL) of water.
After a nasogastric (NG) tube has been inserted, which finding helps the nurse determine that the tube is in the proper place?
The pH of the aspirated fluid is measured.
A nurse is assigning the care of a client admitted with appendicitis. The nurse should assign this client's care to:
a registered nurse pulled from the cardiac unit.
The nurse has made rounds on a team of clients. The nurse should discuss which client with the health care provider (HCP)?
a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular
The nurse assesses that a client who has had a partial gastrectomy has a decreased hemoglobin and hematocrit. The nurse explains to the client that the partial gastrectomy has most likely contributed to which deficiency?
a vitamin B12 deficiency
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note
anorexia, nausea, and vomiting.
A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?
bluish discoloration in periumbilical area
A client who had a cholecystectomy has a T-tube for drainage. The nurse measures the amount of bile drainage from the T-tube at the end of each shift. How should the nurse record the drainage?
charting it separately on the output record
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has
cirrhosis
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for
diaphoresis, vomiting, and diarrhea.
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to
drink liquids only between meals.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
increased urine output
The nurse is teaching a client who is recovering from an abdominal-perineal resection with a colostomy about health promotion. What is an expected outcome for a client during the first 2 weeks after surgery?
maintaining a fluid intake of 3000 mL a day
A client has had a nasogastric tube connected to low intermittent suction. What is the client at risk for?
muscle cramping
Prochlorperazine is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which symptom?
nausea
The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
purpura and petechiae
The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage?
smoking cigarettes
Which activity should the nurse encourage the client with a peptic ulcer to avoid?
smoking cigarettes
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?
atrophy of the gastric mucosa
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
loss of 2.2 lb (1 kg) in 24 hours
A client has just returned from surgery for a gastrectomy. The nurse should position the client in which position?
low Fowler's
A client reports having bloody stools to the nurse. What question(s) will the nurse ask the client? Select all that apply.
"Are you having constipation?" "Do you have a history of hemorrhoids?" "When is the last time you had a colonoscopy?"
A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?
"I will ask the surgeon to come speak to you about the procedure."
A client who is scheduled for a colon surgery questions why the healthcare provider has ordered neomycin. What is the best response by the nurse?
"It will decrease the bacteria in your intestine."
A nurse is caring for a client who is postoperative day 3 after an appendectomy. The client is not eating well and reports feeling bloated and slightly queasy. What should be the nurse's priority action?
Complete a thorough gastrointestinal focused assessment.
When caring for a client with hepatitis B, which situation would expose the nurse to the virus?
a blood splash into the nurse's eyes
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as
a canker sore of the oral soft tissues.
The nurse is caring for a 70-year-old male client after a colectomy. The client received chemotherapy before surgery and has hypertension and diabetes mellitus. Which factor(s) would put this client at risk for sepsis? Select all that apply.
age of 70 abdominal surgery diabetes mellitus
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will
allow proper visualization of the large intestine.
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?
autonomy
When evaluating a client for complications of acute pancreatitis, the nurse should observe for
decreased urine output.
A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should
irrigate the NG tube gently with normal saline solution if ordered.
The nurse is assessing the client who had a gastric resection yesterday. Which finding indicates the development of a leaking anastomosis?
pain, fever, and abdominal rigidity
A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?
poor gag reflex
A client with end-stage pancreatic cancer has decided to terminate medical intervention. What should a nurse anticipate when consulting with palliative care?
referral for bereavement counseling
The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)?
elevated prothrombin time (PT)/international normalized ratio (INR)
The nurse is teaching a client about managing a hiatal hernia. Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living?
eliminating smoking and alcohol use
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. What should the nurse do first?
Assess the client for signs of peritonitis.
The nurse is caring for a client who is 24 hours after gastric bypass surgery. The client has experienced four episodes of vomiting in the past 12 hours, each producing between 500 and 800 ml of bright yellow-green liquid emesis. What action should the nurse take?
Contact health are provider for a STAT abdominal x-ray prescription.
In the early postoperative period following abdominal surgery, the nurse notes a bright red, 3″ × 5″ (7.6 × 12.7 cm) area of drainage on the client's dressing. What should be the nurse's first action in response to this observation?
Take the client's vital signs.
A client who had a splenectomy yesterday has a nasogastric (NG) tube. What should the nurse assess to determine the effectiveness of the NG tube?
absence of abdominal distention
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?
serum potassium level of [3 mEq/L (3.0 mmol/L)]
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for?
severe abdominal pain with direct palpation or rebound tenderness
The nurse is instructing a client with diverticulosis about appropriate self-care activities. Which comment(s) by the client would indicate effective teaching? Select all that apply.
"I should follow a diet that is high in fiber." "It is important for me to drink at least 2000 mL of fluid every day." "I should exercise regularly."
The nurse teaches the parents of an infant diagnosed with Hirschsprung disease about the disease. The nurse determines that the parents understand the diagnosis when the parent makes which statement?
"The nerves at the end of the large colon are missing."
A client is experiencing gastroesophageal reflux. What should the nurse teach the client about managing reflux?
Do not lie down for 2 hours after eating.
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
When instructing the unlicensed assistive personnel (UAP) about giving mouth care to a client with a nasogastric (NG) tube, the nurse should give the UAP which instruction?
Use a soft toothbrush to clean the teeth and tongue.
A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?
Using incentive spirometry every 2 hours while awake.
A nurse is caring for a client 1 hour post-laparotomy who reports abdominal pain rating 5/10. What will the nurse prioritize when administering the ordered morphine?
administer the medication before the pain becomes severe
A client with liver and renal failure has severe ascites. On initial shift rounds, the primary nurse finds the indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, the nurse finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
albumin
When assessing a client who has been diagnosed with hepatic cirrhosis, the nurse should obtain which information when conducting a focused assessment? Select all that apply.
current use of alcohol nutritional status. mental status
A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which test based on the client's concerns?
occult blood and organisms
A client with an abdominal perineal resection and colostomy had a nasogastric (NG) tube inserted during surgery. The NG tube will most likely be removed when the client demonstrates which finding?
passage of flatus from the colostomy
What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved?
preparation for emergency surgery
The nurse is assessing a client who is in the icteric phase of hepatitis A. Which is an expected finding?
yellowed sclera
A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process
before the procedure.
A nurse is calling report to the medical-surgical floor staff regarding a client with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply.
cramping pain in the left lower abdominal quadrant bowel irregularity intervals of diarrhea
The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use?
"PPE should be used when you risk exposure to blood or bodily fluids."
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client?
"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."
A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should
collect the specimen in a sterile container.
A client is admitted with a diagnosis of ulcerative colitis. What should the nurse assess the client for?
bloody, diarrheal stools
A nurse is caring for a client after a hemorrhoidectomy. Which order would the nurse question on the medical record?
low-fiber diet
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds the client very difficult to arouse. The diagnostic information which best explains the client's behavior is
subnormal serum glucose and elevated serum ammonia levels.
A terminally ill client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for palliative care, the nurse can recommend that the client use which measure?
a clear liquid diet
