Ch 42 Upper GI Problems

14. The nurse will plan to teach the patient with newly diagnosed achalasia that a. a liquid or blenderized diet will be necessary. b. drinking fluids with meals should be avoided. c. endoscopic procedures may be used for treatment. d. lying down and resting after meals is recommended.

ANS: C Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Patients are advised to drink fluid with meals. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying.

36. The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order will the nurse implement first? a. Infuse normal saline at 250 mL/hr. b. Administer IV ondansetron (Zofran). c. Provide oral care with moistened swabs. d. Insert a 16-gauge nasogastric (NG) tube.

ANS: A Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.

16. Cobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states, a. "The cobalamin injections will prevent me from becoming anemic." b. "These injections will increase the hydrochloric acid in my stomach." c. "These injections will decrease my risk for developing stomach cancer." d. "The cobalamin injections need to be taken until my inflamed stomach heals."

ANS: A Cobalamin supplementation prevents the development of pernicious anemia. The incidence of stomach cancer is higher in patients with chronic gastritis, but cobalamin does not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis is permanent, and the patient will need lifelong supplementation with cobalamin.

13. A patient has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which nursing action should be included in the postoperative plan of care? a. Elevate the head of the bed to at least 30 degrees. b. Reposition the nasogastric (NG) tube if drainage stops or decreases. c. Notify the doctor immediately about bloody NG drainage. d. Start oral fluids when the patient has active bowel sounds.

ANS: A Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8 to 12 hours. A swallowing study is needed before oral fluids are started.

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

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

25. Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to a. notify the surgeon. b. irrigate the NG tube. c. administer the prescribed morphine. d. continue to monitor the NG drainage.

ANS: A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.

18. A patient who has had several episodes of bloody diarrhea is admitted to the emergency department. Which action should the nurse anticipate taking? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medications. c. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs). d. Provide education about antibiotic therapy.

ANS: A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. NSAIDs may cause occult blood in the stools, but not diarrhea. Antidiarrheal medications usually are avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications.

21. The health care provider orders intravenous (IV) ranitidine (Zantac) for a patient with gastrointestinal (GI) bleeding caused by peptic ulcer disease. When teaching the patient about the effect of the medication, which information will the nurse include? a. "Ranitidine decreases secretion of gastric acid." b. "Ranitidine neutralizes the acid in the stomach." c. "Ranitidine constricts the blood vessels in the stomach and decreases bleeding." d. "Ranitidine covers the ulcer with a protective material that promotes healing."

ANS: A Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response beginning "Ranitidine neutralizes the acid" describes the effect of antacids. And the response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

32. When counseling a patient with a family history of stomach cancer about ways to decrease risk for developing stomach cancer, the nurse will teach the patient to avoid a. smoked foods such as bacon and ham. b. foods that cause abdominal distention. c. chronic use of H2 blocking medications. d. emotionally or physically stressful situations.

ANS: A Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distention are not associated with an increased incidence of stomach cancer.

30. Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease? a. "Avoid foods that cause pain after you eat them." b. "High-protein foods are least likely to cause pain." c. "You will need to remain on a bland diet indefinitely." d. "You should avoid eating many raw fruits and vegetables."

ANS: A The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this and some patients may tolerate these well. High-protein foods help to neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

27. A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. To avoid recurrence of these symptoms, the nurse teaches the patient to a. lie down for about 30 minutes after eating. b. choose foods that are high in carbohydrates. c. increase the amount of fluid intake with meals. d. drink sugared fluids or eat candy after each meal.

ANS: A The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

23. A patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. periodically aspirates and tests gastric pH. b. monitors arterial blood gas values on a daily basis. c. checks each stool for the presence of occult blood. d. measures the amount of residual stomach contents hourly.

ANS: A The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

34. Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse? a. The patient has taken only sips of water. b. The patient is lethargic and difficult to arouse. c. The patient's chart indicates a recent resection of the small intestine. d. The patient has been vomiting several times a day for the last 4 days.

ANS: B A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.

2. A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the patient? a. A glass of orange juice b. A dish of lemon gelatin c. A cup of coffee with cream d. A bowl of hot chicken broth

ANS: B Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

38. Which of these assessment findings in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient has absent breath sounds throughout the left lung. c. The patient has decreased bowel sounds in all four quadrants. d. The patient complains of 6/10 (0 to 10 scale) abdominal pain.

ANS: B Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

22. The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. prevent aspiration of gastric contents. b. inhibit the development of stress ulcers. c. lower the chance for H. pylori infection. d. decrease the risk for nausea and vomiting.

ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.

17. A patient with peptic ulcer disease associated with the presence of Helicobacter pylori is treated with triple drug therapy. The nurse will plan to teach the patient about a. sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol). b. amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec). c. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix). d. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).

ANS: B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.

24. A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next? a. Irrigate the NG tube. b. Obtain the vital signs. c. Listen for bowel sounds. d. Give the ordered antacid.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action that should be taken.

33. Which assessment finding in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider? a. Absent bowel sounds b. Scant nasogastric (NG) tube drainage c. Complaints of incisional pain d. Temperature 102.1° F (38.9° C)

ANS: D An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

7. When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

1. A patient with deep partial-thickness burns experiences severe pain associated with nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. The patient NPO for 2 hours before and after dressing changes. b. Avoid performing dressing changes close to the patient's mealtimes. c. Administer the prescribed morphine sulfate before dressing changes. d. Give the ordered prochlorperazine (Compazine) before dressing changes.

ANS: C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea/vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.

26. The nurse implements discharge teaching for a patient following a gastroduodenostomy for treatment of a peptic ulcer. Which patient statement indicates that the teaching has been effective? a. "Persistent heartburn is expected after surgery." b. "I will try to drink liquids along with my meals." c. "Vitamin supplements may be needed to prevent problems with anemia." d. "I will need to choose foods that are low in fat and high in carbohydrate."

ANS: C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs.

29. The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. antacids 30 minutes before the sucralfate. b. sucralfate at bedtime and antacids before meals. c. antacids after eating and sucralfate 30 minutes before eating. d. sucralfate and antacids together 30 minutes before each meal.

ANS: C Sucralfate is most effective when the pH is low and should not be given with or soon after antacid. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

37. After receiving change-of-shift report, which patient should the nurse assess first? a. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 96/54 mm Hg d. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled

ANS: C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

41. A patient with acute gastrointestinal (GI) bleeding is receiving normal saline IV at a rate of 500 mL/hr. Which assessment finding obtained by the nurse is most important to communicate immediately to the health care provider? a. The patient's blood pressure (BP) has increased to 142/94 mm Hg. b. The nasogastric (NG) suction is returning coffee-ground material. c. The patient's lungs have crackles audible to the midline. d. The bowel sounds are very hyperactive in all four quadrants.

ANS: C The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when a patient has GI bleeding.

11. A 62-year-old patient who has been diagnosed with esophageal cancer tells the nurse, "I know that my chances are not very good, but I do not feel ready to die yet." Which response by the nurse is most appropriate? a. "You may have quite a few years still left to live." b. "Thinking about dying will only make you feel worse." c. "Having this new diagnosis must be very hard for you." d. "It is important that you be realistic about your prognosis."

ANS: C This response is open-ended and will encourage the patient to further discuss feelings of anxiety or sadness about the diagnosis. Patients with esophageal cancer have only a low survival rate, so the response "You may have quite a few years still left to live" is misleading. The response beginning, "Thinking about dying" indicates that the nurse is not open to discussing the patient's fears of dying. And the response beginning, "It is important that you be realistic," discourages the patient from feeling hopeful, which is important to patients with any life-threatening diagnosis.

10. A patient who recently has been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

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

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

12. Which information will the nurse include when teaching a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may be helpful in reducing your symptoms." b. "You should avoid eating between meals to reduce acid secretion." c. "Vigorous physical activities may increase the incidence of reflux." d. "It will be helpful to keep the head of your bed elevated on blocks."

ANS: D Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

6. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."

ANS: D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

9. After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which diet choice for a snack 2 hours before bedtime indicates that the teaching has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Peanut butter sandwich d. Cherry gelatin and fruit

ANS: D Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods like chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

28. A patient who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. the benefits of misoprostol (Cytotec) in protecting the gastrointestinal (GI) mucosa.

ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.

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

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

31. A patient with a recent 20-pound unintended weight loss is diagnosed with stomach cancer. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

ANS: D The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

8. A patient with recurring heartburn receives a new prescription for esomeprazole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. neutralizes stomach acid and provides relief of symptoms in a few minutes. b. reduces the reflux of gastric acid by increasing the rate of gastric emptying. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

15. A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of fat in the diet. b. history of recent weight gain or loss. c. any family history of gastric problems. d. use of nonsteroidal anti-inflammatory drugs (NSAIDs).

ANS: D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.