HESI Prep: Gastrointestinal System

A client with ascites has been scheduled for a paracentesis. Which intervention would the nurse implement immediately before the procedure?

Instruct the client to void. - The bladder should be empty to avoid injury during insertion of the abdominal trocar. The upright position is preferred to allow gravity to aid the accumulation of fluid in the lower abdomen. Although regular monitoring of girth is important, it is not necessary immediately before paracentesis. Having the client drink a glass of water is unrelated to the procedure; rather, it is preferable to offer fluids after the procedure if permitted by the health care provider.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care would be implemented during the postoperative period?

Keeping the client's skin around the stoma clean - If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection. Although oral fluids are withheld until peristalsis returns, it is essential that parenteral fluids be administered to replace the losses incurred by surgery. The client is often unable to accept the altered body image and must be given time to adjust before participating actively in self-care.

Upon admitting a client with jaundice and ascites secondary to a 20-year history of excessive alcohol use, which nursing intervention has the priority during the first 48 hours?

Monitor the client's vital signs. - A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Initially, the client's intake is not increased because the increased fluids may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

The nurse provides discharge education for a client who had an incision and drainage of an oral abscess. The nurse would instruct the client to notify the health care provider if which occurs?

Pain with swelling after 1 week - Pain and swelling should subside before 1 week postoperatively. Continued pain may indicate infection. Foul odor of the breath is expected because of dried blood in the oral cavity. Pain associated with swallowing may occur because of generalized trauma resulting from surgery and is expected. Tenderness in the mouth when chewing is expected.

The nurse is teaching a client about a sodium-restricted diet. Which foods should the nurse encourage the client to consume? Select all that apply. One, some, or all responses may be correct.

fruits & vegetables - Most fruits and vegetables are allowed in a sodium-restricted diet. Sliced deli meats are processed and high in sodium. Condiments such as ketchup are high in sodium. Most processed foods such as processed cheese have sodium added to enhance taste and preserve food.

A client is admitted to the hospital with ascites. The client reports drinking a fifth (750 mL) of vodka mixed in orange juice every day for the past 3 months. To assess the potential for withdrawal symptoms, which question is important for the nurse to ask the client?

"When was your last drink of vodka?" - 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 drinking 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.

After a client has a total gastrectomy, which necessary treatment does the nurse plan to include in the discharge teaching?

Monthly injections of cyanocobalamin - Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life. Adequate diet, fluid intake, and exercise should prevent constipation. Weekly injections of iron dextran are not considered routine. Daily replacement therapy of pancreatic enzymes does not affect pancreatic enzymes.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy 6 hours ago. When asked whether there is pain, the client smiles and says, "No." Which action would the nurse take?

Monitor for nonverbal cues of pain. - Asian clients may tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery would 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.

An older adult client who is accustomed to taking enemas periodically to avoid constipation is admitted to a long-term care facility and is bedbound. Which nursing action would be included in the initial plan of care to prevent the client from developing constipation?

Offer a large glass of prune juice with warm water each morning. - Prune juice and warm water can be administered by the nurse to promote defecation. Prune juice irritates the bowel mucosa, stimulating peristalsis. Fiber in the diet increases fecal volume, which stimulates intestinal motility and the reflex for defecation. Enemas should be avoided because they can promote dependency and can result in electrolyte imbalance. The routine use of laxatives promotes dependency. The client is bedbound and is unable to use a commode.

A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. Which information about the purpose of a vagotomy would the nurse include in the client's education?

It decreases acid in the stomach. - vagotomy is a surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce the rate of gastric secretion (e.g. in treating peptic ulcers).

The nurse is caring for a client that is scheduled to have a percutaneous liver biopsy. Which assessment findings warrant the postponement of the procedure? Select all that apply. One, some, or all responses may be correct.

marked ascites + hemoglobin of less than 9 g/dL - To perform a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL (90 mmol/L) should not have a liver biopsy because the client cannot risk a puncture in a hepatic blood vessel. Hemosiderosis is not a reason to postpone a liver biopsy because it is done to detect the presence of hemosiderin. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy because it is done to detect the presence of hepatic cirrhosis. Although a platelet count of 150,000/mm3 (150 × 109/L) is within the low range of the expected platelet count for an adult, a liver biopsy is not contraindicated. A count of less than 50,000/mm3 (50 × 109/L) is critical and requires postponement of the test.

A client has a liver biopsy. Which nursing intervention is appropriate for monitoring or preventing a post-liver biopsy complication?

Assess the client for pain in the right upper quadrant. - If there is bleeding, subcapsular accumulation of blood will occur and cause pressure and pain in the area of the liver. Placing the client in a left side-lying position is to no avail, because the liver is on the right side of the body. A right side-lying or supine position is maintained for 1 to 2 hours. Taking the client's pulse and blood pressure every shift is too infrequent. Performing this every 15 minutes for 2 hours and then every 30 minutes for 2 hours is more appropriate.

The nurse is assessing a client for possible malabsorption syndrome. Which stool assessment finding supports this diagnosis?

Fat globules - Undigested fat in the feces (steatorrhea) is associated with diseases of the intestinal mucosa (e.g., celiac sprue) or pancreatic enzyme deficiency. Darkening of feces by blood pigments (melena) is related to upper gastrointestinal (GI) bleeding. Bright red blood in the stool is related to lower GI bleeding (e.g., hemorrhoids). Stools containing blood and mucus (currant jelly stools) are associated with intussusception.

Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct.

Fever, diarrhea & abdominal cramps - The inflammatory process can promote a fever and tends to increase peristalsis, causing intestinal spasms and diarrhea. As ulceration occurs, the loss of blood leads to anemia. The client will lose weight (not gain it) because of anorexia and malabsorption. Hemoptysis (coughing up blood from the respiratory tract) is not a related sign.

The nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. Which does the nurse conclude is the probable cause of ascites?

Impaired portal venous return - An enlarged liver impairs venous return leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. Which is an important nursing intervention?

Observe the client for increasing confusion. - An increased serum ammonia level impairs the central nervous system, causing an altered level of consciousness. Increasing ammonia levels are not related to weight. An alteration in fluid intake will not affect the serum ammonia level. Measuring the client's urine specific gravity is not the priority; the priority is to monitor the client's neurological status.

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. Which response does the nurse conclude that the client is experiencing?

The client is experiencing denial; the client is having difficulty accepting reality. - 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.

Which recommendation is important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Use lemon juice to season meat. - Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.

A client with a recent colostomy expresses concern about the inability to control the passage of gas. Which recommendation would the nurse make?

Avoid foods that in the past caused flatus. - In general, foods that caused flatus preoperatively will continue to do so after a colostomy. Foods high in fiber necessarily are not related to formation of flatus. Reducing foods high in fiber can result in constipation; a regular diet is encouraged. Decreasing fluid intake at mealtimes is not a factor in the formation of flatus. A bland diet may be used initially after the colostomy, but then the client should progress to a regular diet; to control the formation of flatus, the client should eliminate foods that produce gas.

After recovering from gastrointestinal surgery, a client is prescribed a regular diet. To minimize stomach irritation, the nurse would encourage the client to consume which food?

Baked fish - Baked fish is a low-residue, low-fat, high-protein, and non-gas-producing food that usually is tolerated well. Fresh fruit has fiber that irritates the gastrointestinal tract. Bran cereal has fiber that irritates the gastrointestinal tract. Whole milk irritates the gastrointestinal tract and stimulates mucus production.

A client who has just been transferred to the inpatient unit after surgery for oral carcinoma indicates to the nurse that the client's spouse is the only person who is allowed to visit. To support the client at this time, which action would the nurse take?

Comply with the client's wishes. - Complying with the client's wishes meets the client's immediate personal needs and demonstrates respect and concern. Asking why the client does not want others to visit may be explored when planning further support; it is not the priority at this time. Having the spouse explain to the client that everything will be okay provides false reassurance that may block communication; the nurse, not the spouse, should explore this issue with the client. The client's immediate request should be met first; feelings may be explored when the client reflects a readiness to communicate.

The nurse is creating a discharge teaching plan for a client who had a subtotal gastrectomy. The nurse would include which instructions about minimizing dumping syndrome? Select all that apply. One, some, or all responses may be correct.

Eat small, frequent meals. + lie down for 1 hour after eating - Small, frequent meals keep the volume within the stomach to a minimum at any one time, limiting dumping syndrome. Lying down delays emptying of the stomach contents, which will limit dumping syndrome. Fluids should be taken between meals to decrease the volume within the stomach at one time. Dumping syndrome occurs after eating because of the rapid movement of food into the jejunum without the usual digestive mixing in the stomach and processing in the duodenum. Chewing a set number of times before swallowing is not pertinent to solving this problem. High fiber, complex carbohydrates, moderate fats, and high protein in small, frequent meals are recommended to prevent dumping syndrome.

The nurse is providing dietary teaching to a client receiving a high-protein diet while recovering from an acute episode of colitis. Which would the nurse include in the rationale for this diet?

Repairs tissues - Protein is required for the building and repair of intestinal tissues. Increased protein will not affect peristalsis significantly. Anemia may result from chronic bleeding; usually, it is corrected with increased iron intake. Muscle tone is affected by exercise or lack of exercise.

An older adult is returned to the surgical unit after having a subtotal gastrectomy. The nurse anticipates that which dietary modification will be prescribed?

Resume small, easily digested feedings gradually. - Small, frequent feedings are tolerated best after a subtotal gastrectomy. As soon as edema subsides, the individual generally is given small amounts of fluid, and then the diet is progressed gradually. Roughage may be irritating to the gastrointestinal (GI) tract after surgery. Clients are advised to slowly bring dairy products back into the diet. Some people may become lactose intolerant after having a gastrectomy. Clients are advised to drink no more than 4 ounces (½ cup) of liquid during meals. This allows the client to eat enough solid food without getting too full and will slow down the digestion of the food.

A client suspected of having salmonellosis asks the nurse how a diagnosis is confirmed. The nurse responds that a medical diagnosis is established with which laboratory test?

Stool culture - Salmonella bacilli can be visualized via microscopic examination of stool. Although a urinalysis may be done, it is not definitive for the diagnosis of salmonellosis. Although a febrile agglutinin test may be done, it is not definitive for the diagnosis of salmonellosis. Although a complete blood count may be done, it is not definitive for the diagnosis of salmonellosis.