Gastrointestinal questions
The nurse is caring for a client with ulcerative colitis. The client is scheduled to undergo a total proctocolectomy. Which statement made by the client indicates an understanding of the procedure? A. "I am going to have my colon, rectum, and anus removed." B. "The doctor will remove a part of the colon and lymph nodes." C. "The doctor will remove the right side of my colon and diseased ileum." D. "The doctor is going to take out the left side of my colon."
A. "I am going to have my colon, rectum, and anus removed." Rationale: Option A: This is a correct description of the procedure. Option B: This describes a colectomy. Option C: This describes an ileocolectomy. Option D: This describes a hemicolectomy.
Where is bile produced? A. Liver B. Pancreas C. Small intestine D. Stomach
A. Liver Bile is produced in the liver and stored in the gallbladder.
The nurse is teaching a client about prevention of diarrhea. Which action will the nurse include in the teaching? A. Practicing proper hand hygiene B. Enteral feedings should be half strength C. Encourage taking a bulk-forming laxative D. Teach the client to increase dairy intake
A. Practicing proper hand hygiene Rationale: Option A: Proper hand hygiene is important to avoid contaminating food. Option B: Enteral feedings should be full strength to avoid contamination when diluting food. Option C: A bulk-forming laxative is for constipation. Option D: Dairy is not recommended for those experiencing diarrhea. Test Taking Tip: The number-one cause of diarrhea is contaminated food or water.
The nurse is caring for a client with celiac disease. Which clinical manifestations can the nurse expect to find? A. Steatorrhea B. Constipation C. Itching D. Weight gain
A. Steatorrhea Definition: an increase in fat excretion in the stools. Rationale: Option A: This is a common finding in a client with celiac disease. Option B: Frequent loose stools are found in clients with celiac disease. Option C: Itching is not a symptom of celiac disease. Option D: Weight loss is associated with celiac disease.
The nurse is providing teaching to a client who underwent a hernia repair. Which intervention will the nurse include in the teaching? A. Teach the client to apply a support truss while still lying in bed B. Inform client that bleeding is normal for 2-3 weeks after surgery C. Instruct the client to avoid lifting for 3 days D. Encourage client to cough and breathe deeply
A. Teach the client to apply a support truss while still lying in bed Rationale: Option A: This statement is accurate and should be included in the teaching. Option B: Bleeding after this procedure is abnormal, and the client should be instructed to notify the health-care provider. Option C: The client should avoid lifting for 2-6 weeks. Option D: Coughing should be avoided, but the client is encouraged to breathe deeply.
The nurse is caring for a client who became dehydrated because of diarrhea. Which clinical manifestations will the nurse expect to find? Select all that apply. A. Bradycardia B. Dry mucous membranes C. Decreased skin turgor D. Weakness E. Thready pulse
B, C, D, E Dry mucous membranes, decreased skin turgor, weakness, and thready pulse Rationale Option A: Tachycardia is a clinical manifestation of dehydration. Option B: Dry mucous membranes are a sign of dehydration. Option C: Decreased skin turgor (decreased elasticity) is a sign of dehydration. Option D: Weakness is common in clients with dehydration. Option E: Clients with dehydration typically have a thready pulse.
The nurse is preparing a presentation regarding risk factors for diverticulitis. Which contributing factor for developing diverticulitis will the nurse include in the presentation? Select all that apply. A. High-fiber diet B. Sedentary lifestyle C. Smoking D. Diet high in animal fat E. Obesity
B, C, D, E Sedentary lifestyle, Smoking, Diet high in animal fat, Obesity Rationale: A sedentary lifestyle and a diet high in animal fat can contribute to diverticulitis. Smoking and obesity are risk factors for diverticulitis. A low-fiber diet can contribute to diverticulitis.
The nurse is caring for a client with malabsorption. The nurse identifies which contributing factors as probable causes? Select all that apply. A. Appendicitis B. Celiac disease C. Lactose intolerance D. Pancreatitis E. Parasitic disease
B, C, E Celiac disease, lactose intolerance, and parasitic disease
The nurse is caring for a group of clients. Which client should the nurse see first? A. A client with celiac disease reporting loose stools B. A client with a bowel obstruction vomiting fecal matter C. A client with colon cancer who underwent a colostomy yesterday D. A client with malabsorption receiving electrolyte replacement
B. A client with a bowel obstruction vomiting fecal matter
The nurse is caring for a client with a bowel obstruction. Which intervention will the nurse implement? A. Place the client on a clear liquid diet B. Administer a nasogastric tube as prescribed C. Manually disimpact stool D. Place the client in a supine position in bed
B. Administer a nasogastric tube as prescribed Rationale: Option A: The client will be NPO. Option B: The nurse should insert a nasogastric tube to decompress the bowel. Option C: The nurse should not disimpact a client unless it has been prescribed. Option D: Semi-Fowler's position will relieve abdominal pressure.
The nurse is caring for a client with cirrhosis. The nurse should anticipate reviewing which lab value? A. Amylase 180 units/L B. Ammonia 80 mcg/dL C. Albumin 4.2 g/dL D. Lipase 52 units/L
B. Ammonia 80 mcg/dL Option A: Amylase is normal; it is elevated in clients with pancreatic disease (Regular 30-110 U/L) Option B: The ammonia level is high, which is an anticipated finding for clients with liver disease (Regular 15-45 mcg/dL) Option C: This Albumin value is typically low in clients with liver disease, but this level is normal (Regular 3.4-5.4 g/dL) Option D: This Lipase value is elevated in clients with pancreatic diseases (Regular 0-150 U/L)
The nurse is caring for a client with Crohn's disease. Which clinical manifestation can the nurse expect to find? A. Insomnia B. Crampy abdominal pain C. Constipation D. Weight gain
B. Crampy abdominal pain Rationale: Option A: Insomnia is not a clinical manifestation of Crohn's disease. Option B: Crampy abdominal pain is a symptom of Crohn's disease. Option C: Diarrhea is a clinical manifestation of Crohn's disease. Option D: Weight loss is a clinical manifestation of Crohn's disease.
The nurse is caring for a client with appendicitis. Which intervention will the nurse implement? A. Place the client in a supine position B. Ensure the client does not take anything by mouth C. Apply a heating pad to the abdominal area D. Administer an enema as prescribed
B. Ensure the client does not take anything by mouth Rationale: Option A: The client should be placed in semi-Fowler position to help reduce pain. Option B: The client should remain NPO for surgery. Option C: Heat should be avoided because it can cause or complicate a rupture. Option D: Enemas can cause or complicate a rupture and should be avoided.
The nurse is caring for a client with appendicitis who begins to exhibit nausea, vomiting, fever, and abdominal rigidity. Which action will the nurse take? A. Apply heat to the client's abdomen B. Notify the health-care provider immediately C. Encourage the client to increase fluids D. Assess client's potassium level
B. Notify the health-care provider immediately Rationale: Option A: Heat can cause further complications. Option B: These symptoms are indicative of peritonitis and require immediate notification of the health-care provider. Option C: The client will remain NPO. Option D: Although fluid and electrolytes will be monitored, the nurse needs to have an order, and this is not the priority.
The nurse is teaching a client about a barium enema. Which statement by the client indicates an understanding of the teaching? A. "I will eat a high-residue diet for several days before the test." B. "I will have nothing by mouth for 2 hr before the test." C. "I need to take a laxative and enema the night before the test." D. "I can have only clear liquids for 8 hr before the test."
C. "I need to take a laxative and enema the night before the test." Rationale: Option A. The client should eat a low-residue diet for several days before the test. Option B: The client is NPO for 8 hr before the test. Option C: The client will require a laxative and enema the night before the test. Option D: The client should follow a clear liquid diet for 24 hr before the test.
The nurse is caring for a client with an obstruction. The client begins to experience fecal vomiting. Which action should the nurse take? A. Administer 0.9% normal saline B. Insert a nasogastric tube C. Notify the health-care provider (HCP) D. Administer an enema
C. Notify the health-care provider (HCP) Rationale: Option A: The nurse cannot administer intravenous fluid without an order. Option B: The nurse cannot perform a NG tube procedure without an order. Option C: The nurse should notify the HCP because the obstruction is becoming worse. Option D: The nurse cannot perform any procedure without an order
The nurse is caring for a client with a new ostomy. Which color does the nurse expect to see upon assessment of the stoma? A. Bluish B. Black C. Red D. Green
C. Red Rationale: Option A: A bluish stoma indicates inadequate blood supply. Option B: A black stoma indicates necrosis. Option C: A red stoma indicates healthy blood supply. Option D: A stoma will not be green.
How many loose stools in 24 hr will a client experience before diarrhea is diagnosed? A. One B. Two C. Three D. Four
C. Three Rationale: Diarrhea is classified as more than three loose stools daily.