Ch 48: Assessment of the Gastrointestinal System

A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate?

Remind the client that a small amount of bleeding is possible.

The nurse is caring for a client with a large bowel obstruction due to fecal impaction. What position would be appropriate for the client while in bed?

Semi-Fowler

After teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC), the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"I will take this medication with my breakfast each morning."

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug?

"Do you have any allergy to sulfa drugs?"

The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching?

"Drink plenty of fluids to prevent dehydration."

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis?

Esophagogastroduodenoscopy (EGD)

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first?

Heart rate and rhythm

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect?

High-pitched, rushing bowel sounds in the right lower quadrant

The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.)

Intolerance of fatty foods Pernicious anemia

The nurse is interviewing a client who reports having abdominal cramping, bloating, and diarrhea after drinking milk or ingesting other dairy products. What health problem does the client most likely have?

Lactose intolerance

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client?

Left lateral

A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client's abdomen?

Lightly palpate the RUQ last.

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?

Liver

The nurse is caring for a client experiencing upper gastrointestinal (GI) bleeding. What is the priority action for the client's care?

Maintain airway, breathing, and circulation.

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect?

Melena

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that apply.)

Obtain vital signs every 15 to 30 minutes until alert. Assess the client for rectal bleeding and severe pain. Confirm the client has a ride home and plans to rest.

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client?

Occult blood test

The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider?

Pale and bluish stoma

A client has a nasogastric (NG) tube as a result of an upper gastrointestinal (GI) hemorrhage. What comfort measure would the nurse remind assistive personnel (AP) to provide?

Performing frequent oral care

Which of the following is (are) (a) risk factor(s) for gastric cancer? (Select all that apply.)

Achlorhydria Chronic atrophic gastritis H. pylori infection Pernicious anemia

A nurse is preparing to administer pantoprazole intravenously to prevent stress ulcers during surgery. What action(s) by the nurse is (are) most appropriate? (Select all that apply.)

Administer the drug through a separate IV line. Infuse pantoprazole using an IV pump. Use an in-line IV filter when infusing.

A client is admitted with a large oral tumor. What assessment by the nurse takes priority?

Airway

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.)

Ammonia: liver Lipase: pancreas

The nurse is caring for a client with sialadenitis. What comfort measures are appropriate for this client? (Select all that apply.)

Applying warm compresses Offering fluids every hour

A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.)

Apricots Potato soup

A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be appropriate?

Arrange a dietary consult.

A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink, What action by the nurse is appropriate?

Assess the client's gag reflex.

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.)

a. Nausea and vomiting abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions would the nurse include in this client's assessment? (Select all that apply.)

"Which food types cause an exacerbation of symptoms?" "Where is your pain or discomfort and what does it feel like?"

A client is preparing to have a fecal occult blood test (FOBT). What health teaching would nurse include prior to the test?

"You need to avoid red meat and NSAIDS for 48 hours before the test."

The nurse is teaching a client diagnosed with stomatitis about special mouth care. Which statement by the client indicates a need for further teaching?

"I will use a more firm toothbrush to keep my mouth clean."

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching?

"I'll cook all the meals for my family."

A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?

"It's a good thing I love orange and cherry gelatin."

The nursing is teaching a client diagnosed with gastroesophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.)

"Avoid taking any NSAIDS like ibuprofen for 10 days before the procedure." "Contact the primary health care provider after the procedure if you have increased pain.

The primary health care provider documents that a client has a bruit over the abdominal aorta. What teaching will the nurse provide for assistive personnel (AP) based on this assessment finding?

"Avoid washing the client's abdomen too aggressively."

The nurse is teaching a client about the use of viscous lidocaine for oral pain. What health teaching would the nurse include?

"Be sure to check food temperatures before eating."

The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug?

"Be sure to take this drug with food and water to help manage constipation."

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best?

"Changes in your liver cause drugs to be metabolized differently."

A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection. What health teaching related to bismuth would the nurse include?

"Do not take aspirin or aspirin products of any kind while on bismuth.'

The nurse working with older clients understands age-related changes in the gastrointestinal system Which changes does this include? (Select all that apply.)

Decreased hydrochloric acid production Diminished sensation that can lead to constipation Fat not digested as well in older adults Pancreatic vessels become calcified

A client who had a partial gastrectomy 3 days ago begins to experience vertigo, sweating, and tachycardia about 30 minutes after eating breakfast. What postoperative complication would the nurse suspect?

Dumping syndrome

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease (GERD). What assessment finding(s) would the nurse expect? (Select all that apply.)

Dyspepsia Regurgitation Belching Coughing Chest discomfort Dysphagia

The nurse is caring for a client who is diagnosed with a complete small bowel obstruction. For what priority problem is this client most likely at risk?

Electrolyte imbalance

The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.)

Decreased blood pressure Dizziness Hematemesis Decreased urinary output

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.)

B. Use medicated wipes instead of toilet paper. D. Apply a thin coat of aloe cream to the perineum. E. Gently pat the perineum dry after cleansing.

After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching?

Baked fish with steamed carrots and a glass of apple juice

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client's understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

Broiled chicken with brown rice, steamed broccoli, glass of apple juice

A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse teaches the client and family about the signs of potential complications which include what problems?

Cholangitis Pancreatitis Perforation Sepsis

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute?

Clay-colored stools

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder?

Consuming raw seafood

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.)

a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? e. How many bathrooms are in your home?

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)

a. Lower gastrointestinal bleeding erosion of the bowel wall b. Abscess formation-localized pockets of infection develop in the ulcerated bowel lining d. Nonmechanical bowel obstruction-paralysis of colon resulting from colorectal cancer

The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that аpply.)

a. Need to have drug administered by a primary health care provider. b. Need to avoid crowds and individuals who have infection. d. Awareness of a rare but potentially fatal drug complication. e. Need to report any signs and symptoms of infection immediately.

A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug?

"Have you been experiencing any constipation?"

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching?

"I can continue smoking cigarettes which is better than chewing tobacco."

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching?

"I will take a laxative nightly at bedtime to avoid becoming constipated."

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction?

Alvimopan

The nurse is caring for a client who had an open traditional esophagectomy. Which assessment findings would the nurse report immediately to the primary health care provider?

Wound dehiscence Fever Tachycardia

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification?

Proton pump inhibitor

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min. What action by the nurse is appropriate?

Provide physical stimulation.

A nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula, Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions?

Serum potassium of 2.6 mEq/L (2.6 mmol/L)

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action?

Skin protection

A client with peptic ulcer disease is in the emergency department and reports gastric pain that has gotten much worse over the last 24 hours. The client's blood pressure when lying down is 112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse most appropriate?

Start a large-bore IV with normal saline.

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor?

Upper gastrointestinal (GI) bleeding

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.

a. Administer pain medications as prescribed. b. Palpate the abdomen for distention. c. Assess for sudden changes in mental status. E.Evaluate stools for occult blood.

What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (Select all that apply.)

Administer vitamin B12 injections. Ask the primary health care provider about folic acid replacement. Provide iron supplements for the client.

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.)

Alcohol Caffeine Corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDS)

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastroesophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply.)

Asthma Laryngitis Dental caries Cardiac disease Cancer