Gastrointestinal level 1 Question

A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first? A. Fasten each tube to the bedsheets B. Irrigate each tube with normal saline C. Measure the drainage in the collection devices D. Ensure that all tubes are attached to collection devices

D.Ensure that all tubes are attached to collection devices RATIONAL: All tubes should be attached to appropriate collection devices to permit drainage. A T-tube should not be fastened to the bedsheets; a T-tube is positioned surgically in the common bile duct, and tension on the tube must be avoided to prevent accidental removal. A T-tube drains by gravity and is not irrigated. Measuring the drainage in the collection devices is not the priority at this time; this will be done later at the change of shift or when the collection devices are full.

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites? A. Impaired portal venous return B. Impaired thoracic lymph channels C. Excess production of serum albumin D. Enhanced hepatic deactivation of aldosterone secretion

A. Impaired portal venous return The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.

A client is diagnosed with cancer of the pancreas and is apprehensive and restless. Which nursing action should be included in the plan of care? A. Encouraging expression of concerns B. Administering antibiotics as prescribed C. Teaching the importance of getting rest D. Explaining that everything will be all right

A. Encouraging expression of concerns RATIONAL: Open communication helps to decrease anxiety. Antibiotics will have no direct effect on the client's anxiety. Knowledge does not always reduce anxiety and promote rest. Explaining that everything will be all right is false reassurance.

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history? A. Acute gastritis B. Diabetes mellitus C. Partial gastrectomy D. Unhealthy dietary habits

C. Partial gastrectomy Rational: Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum). Hemorrhaging may cause anemia; however, pernicious anemia occurs when the intrinsic factor is not produced. The beta cells of the pancreas are not involved in secretion of intrinsic factor. Dietary intake does not affect the production of intrinsic factor.

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "What prompts your drinking episodes?" C. "Do you also eat when you drink?" D."Why do you mix the vodka with orange juice?"

A. "When was your last drink of vodka?" Rational : The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A client with a 20-year history of excessive alcohol use has developed jaundice and ascites and is admitted to the hospital. What is the priority nursing action during the first 48 hours after the client's admission? A. Monitor vital signs B. Increase fluid intake C. Obtain a foam mattress D. Improve nutritional status

A. Monitor vital signs RATIONAL: The vital signs, especially pulse and temperature, will increase before the client demonstrates any of the more severe signs and symptoms of withdrawal from alcohol. Increasing fluid intake is contraindicated initially because it may cause cerebral edema and the client has ascites. Although the client will be more comfortable on a foam mattress, it is not the priority. Improving nutritional status becomes a priority after problems of the withdrawal period have subsided.

A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? A. Fatigue B. Anorexia C. Yellow urine D. Clay-colored stools

D. Clay-colored stools Rational: Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.

A nurse is caring for a client who just had a liver biopsy. After the procedure, the nurse should monitor for which common complication associated with the biopsy? A. Hemorrhage B. Gastroparesis C. Pulmonary embolism D. Tension pneumothorax

A. Hemorrhage In the impaired liver, blood-clotting mechanisms are disrupted, and hemorrhage may occur from the trauma of this invasive procedure. A liver biopsy will not cause the stomach to empty more slowly. Because clotting mechanisms are prolonged, emboli usually are not a complication. A collapsed lung can occur if the needle is not inserted properly; however, this is not a common occurrence.

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted? A. Supine B. Mid-Fowler C. High-Fowler D. Trendelenburg

C. High-Fowler RATIONAL: The high-Fowler position promotes optimal entry into the esophagus aided by gravity. Supine position does not take full advantage of the effect of gravity. Mid-Fowler and Trendelenburg positions will contribute to aspiration. The head of the bed should be raised, not lowered.

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance? A. Dry, pale pink, and flush with the skin B Moist, red, and raised above the skin surface C. Dry, purple, and depressed below the skin surface D. Moist, pink, flush with the skin, and painful when touched

B Moist, red, and raised above the skin surface RATIONAL. The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. The stoma should be moist, not dry; pale pink indicates a low hemoglobin level. Although some stomas can be flush with the skin, a raised stoma is more common. The stoma should be moist, not dry; purple indicates compromised circulation. A depressed stoma is retracted and unexpected. Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? A. "My blood type is A positive." B. "I smoke one pack of cigarettes a day." C. "I have been overweight most of my life." D. "My blood pressure has been high lately."

B. "I smoke one pack of cigarettes a day." Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

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. The nurse concludes that the client is experiencing what response? A. Reaction formation; this is related to the client's recent altered body image B. Denial; the client is having difficulty accepting reality C. Impotency resulting from the surgery; sexual counselling may be indicated D. Suicidal thoughts; consultation with a psychiatrist should be prescribed

B. Denial; the client is having difficulty accepting reality rational: 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.

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention? A. Emphasizing that it is essential that the client can care for the ileostomy without assistance B. Evaluating the client's ability to care for the ileostomy C. Ensuring that the client understands the dietary limitations that must be followed D. Ensuring that the client is competent at changing the dry sterile dressing on the incision

B. Evaluating the client's ability to care for the ileostomy The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge. People should not be pressured into performing self-care before they are physically and emotionally ready. The diet is not limited; however, the client should be encouraged to eat a high-protein diet or a regular diet with supplemental protein. A high-fluid intake should be maintained. Often the client no longer needs a dressing on the incision at the time of discharge; a collection pouch is used over the stoma.

A client is diagnosed with a peptic ulcer. What should the nurse expect when assessing the client's pain? A. Intensifies after vomiting B. Occurs one to three hours after meals C. Increases when an excess of fatty foods is ingested D. Begins in the epigastrium, then radiates to the abdomen

B. Occurs one to three hours after meals RATIONAL: 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; eating generally alleviates pain. Pain associated with the ingestion of fatty foods is associated with cholecystitis. Pain is localized in the epigastrium; it radiates to the abdomen only if the ulcer has perforated.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? A. Exercise to improve circulation B. Eat bland foods and avoid spices C. Consume a high-fiber diet and drink adequate water D. Use laxatives to avoid constipation and the Valsalva maneuver

C. Consume a high-fiber diet and drink adequate water RATIONAL:Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? A. Offering psychological support B. Monitoring the client's fluid balance C. Keeping the client's respiratory passages patent D. Providing a pad and pencil for writing messages

C. Keeping the client's respiratory passages patent RATIONAL: A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.

A client is admitted to the hospital with jaundice. After numerous diagnostic tests, the healthcare provider makes the diagnosis of cancer of the pancreas. What does the nurse conclude is the most likely cause of the client's jaundice? A.Necrosis of the parenchyma caused by the neoplasm B. Excessive serum bilirubin caused by red blood cell destruction C. Obstruction of the common bile duct by the pancreatic neoplasm D. Impaired liver function, resulting in incomplete bilirubin metabolism

C. Obstruction of the common bile duct by the pancreatic neoplasm The common bile duct passes through the head of the pancreas; it often is constricted or obstructed by the neoplasm, 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 teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? A. Urinary retention B. Gastric hyperacidity C. Rebound tenderness D. Increased lower bowel motility

C. Rebound tenderness RATIONAL: Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

An older adult is returned to the surgical unit after having a subtotal gastrectomy. Which dietary modification should the nurse anticipate that the healthcare provider will most likely prescribe? A. Increase intake of dietary roughage quickly B. Avoid oral feedings for a prolonged period C. Resume small, easily digested feedings gradually D. Limit intake to self-selection of personally preferred foods

C. Resume small, easily digested feedings gradually Small, frequent feedings are tolerated best after a subtotal gastrectomy. Roughage may be irritating to the gastrointestinal (GI) tract after surgery. As soon as edema subsides, the individual generally is given small amounts of fluid, and then the diet is progressed gradually. Allowing only personal food preferences does not ensure inclusion of nutrients necessary for recovery.

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis? A. Turkey salad, french fries, sherbet B. Cottage cheese, mixed fruit salad, milkshake C. Salad, sliced chicken sandwich, gelatin dessert D. Cheeseburger, tortilla chips, chocolate pudding

C. Salad, sliced chicken sandwich, gelatine dessert RATIONAL: The diet should be high in carbohydrates, with moderate protein and fat content. Salad, chicken and gelatin 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 virus injures the intestinal mucosa. Cheeseburger, tortilla chips, and chocolate pudding are too high in fat.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? A. Offer soft-textured foods to reduce the digestive burden B. Offer low-cholesterol foods to avoid further formation of gallstones C. Increase protein intake to promote tissue healing and improve energy reserves D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

D. Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release Rational: Fat intake stimulates cholecystokinin release that signals the gallbladder to contract, causing pain. Soft-textured foods are unnecessary. Eating low-cholesterol foods to avoid further formation of gallstones is not true for all clients with cholecystitis; low-cholesterol foods are necessary if the cholecystitis is precipitated by cholelithiasis and the stones are composed of cholesterol. An increase in protein intake is necessary to promote tissue healing and improve energy reserves after a cholecystectomy, but is not as important as fat intake for cholecystitis.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? A. Monitor for nonverbal cues of pain B. Check the pressure dressing for bleeding C. Assist the client to ambulate around his room D. Irrigate the client's nasogastric tube with sterile water

A.Monitor for nonverbal cues of pain RATIONAL: Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? A. "There are no dietary restrictions because the tumor has been removed." B. "Your diet should be low in calories to prevent taxing your diseased pancreas." C. "Meals should be restricted in protein because of your compromised liver function." D. "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

D. "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism." Rational: Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs. Clients require small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings. The response "There are no dietary restrictions because the tumor has been removed" is false reassurance. High-calorie meals are needed to provide energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client chooses which breakfast cereal? A. Froot Loops B. Cornflakes C. Cap'n Crunch D. Shredded wheat

D. Shredded wheat Shredded wheat contains the most grams of fiber to prevent constipation. Froot Loops, Cap'n Crunch, and cornflakes are not as high in fiber.

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse? A. "Tell me more about what you are thinking." B. "Products are available to limit this problem." C. "This is a problem, but the surgery is necessary." D. "Most people who have this surgery share this same concern."

A. "Tell me more about what you are thinking." The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client's concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client's concerns.

A nurse is caring for a client with Addison disease. Which dietary instruction should the nurse teach the client to follow? A. Add extra salt to food B. Consume high-potassium foods C.Omit protein foods at each meal D. Restrict the daily intake of fluids to 1 L

A. Add extra salt to food Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to developing hyponatremia. Therefore, the addition of salt to the diet is advised. Clients with Addison disease are prone to hyperkalemia. High-potassium foods can be restricted. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism and healing. Fluids are not restricted for clients with Addison disease.

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include? A. Giving oil-retention enemas daily for two days preoperatively B. Administering cleansing enemas and then neomycin C. Having a Sengstaken-Blakemore tube at the bedside D. A high-protein and high-carbohydrate regular diet for two days preoperatively

B. Administering cleansing enemas and then neomycin rational: After the bowel is cleansed, neomycin is given to decrease gram-negative bacteria in the colon, which should limit postoperative infection. Oil-retention enemas are used to alleviate constipation; oil-retention enemas are not prescribed before surgery because they contaminate the bowel with oil. A Sengstaken-Blakemore tube is used for a client with ruptured esophageal varices, not for a client having a hemicolectomy. A diet to decrease bulk and empty the colon generally is prescribed; usually it is a clear liquid diet.

A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established with what laboratory test? A. Urinalysis B. Stool culture C. Febrile agglutinin test D. Complete blood count

B. Stool Culture Rational: The Salmonella bacilli can be visualized via microscopic examination of stool. Although a urinalysis might be done, it is not definitive for the diagnosis of salmonellosis. Although a febrile agglutinin test might be done, it is not definitive for the diagnosis of salmonellosis. Although a complete blood count might be done, it is not definitive for the diagnosis of salmonellosis.

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client? A. "Have your dinner completed by 6:00 PM tonight and then no food or fluids after that." B. "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." C. "Consume a light evening meal tonight and then no food or fluids after midnight." D. "Eat lunch today and then do not drink or eat anything until after your surgery."

C. "Consume a light evening meal tonight and then no food or fluids after midnight." RATIONAL By eating a light meal and eliminating food and fluids after midnight, complications are limited during and after surgery; these include aspiration, nausea, dehydration, and possible ileus. A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. Clear liquids in the morning can cause nausea, vomiting, and aspiration. Fluids should not be withheld for more than eight hours to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.

A client, experiencing an exacerbation of Crohn disease, is admitted to the hospital for intravenous steroid therapy. The nurse should not assign this client to a room with a roommate who has which illness? A. Pancreatitis B. Thrombophlebitis C. Bacterial meningitis D. Acute cholecystitis

C. Bacterial meningitis RATIONAL: The bacteria that cause meningitis are transmitted via air currents; the client should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

A nurse is caring for a client on the second day after an abdominoperineal resection. Which finding does the nurse document as normal in the stoma? a. Dry, pale pink, and even with the skin B. Moist, skin-colored, and flush with the skin C. Moist, red, and raised above the skin surface D. Dry, purple, and depressed below the skin surface

C. Moist, red, and raised above the skin surface RATIONAL The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface 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.

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? A. Checking for the last bowel movement B. Checking for residual stomach contents C. Checking to determine time of last medication for nausea D. Checking to make sure the head of bed is elevated at least 15 degrees

B. Checking for residual stomach contents RATIONAL:Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel? A. Apply insect repellent. B. Drink only bottled water. C. Avoid drinking pasteurized milk. D. Obtain vaccine prior to foreign travel.

B. Drink only bottled water. Rational: Entamoeba histolytica, the organism that causes amebic dysentery, is transmitted through excreta; bottled water prevents consumption of water that may be contaminated by the causative microorganism. Amebic dysentery is not a mosquito- or tick-borne disease. Pasteurization kills microorganisms that can cause disease. Vaccines do not prevent amebic dysentery.

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? A. Vitamins B. Whole bran C. Cod liver oil D. Amino acids

B. Whole bran Whole bran provides bulk that promotes intestinal motility and a regular bowel movement. 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 is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning? A. Ripe bananas B. Milk products C. Green vegetables D. Creamed potatoes

C. Green vegetables Green vegetables contain fiber, which promotes defecation. Bananas, milk products, and creamed potatoes have a constipating effect, which results in straining at stool.