Invasives GI Exam
Diet for pancreatitis
Low fat diet with small frequent meals (pancreatic enzymes with every meal)
Where is Cullens sign located on the body, and what is it a sign of?
Bruising around bellybutton; pancreatitis
Where is Turners sign located on the body, and what is it a sign of?
Brushlike bruising on abdomen and maybe back; pancreatitis
What are the two types of failure to thrive?
1. Organic- deals with disorder that interferes with nutrient intake, absorption, metabolism, or excretion 2. Nonorganic- environmental neglect, stimulus deprivation, or both
How much gastric residual aspiration would make you consider holding a feeding?
200 mL or more
A nurse is preparing to administer an enteral feeding via an established NG tube. In which order should the following steps take place? 1. Evaluate tolerance to feeding 2. Administer the feeding 3. Verify tube placement 4. Check the residual feeding contents
3, 4, 2, 1
How often is intermittent tube feeding administered?
4 to 6 hours
How long should the nutritional intake of infants be limited to breast milk or formula, along with water?
6 months
A client is scheduled to undergo a liver biopsy. Which lab should the nurse monitor prior to the procedure? a. PT b. Serum lipase c. Bilirubin d. Calcium
A
A nurse is caring for a client who is 4 hrs. postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect? a. Right shoulder pain b. Urine output 20 mL/hr c. Temp 101 d. Oxygen saturation 92%
A
A nurse is caring for a client who is receiving TPN. The nurse should monitor the client for which of the following conditions as a complication TPN? a. Polyuria b. Aspiration c. Abdominal distention d. Stomatitis
A
A nurse is collecting data on a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client's history? a. Gallstones b. GERD c. Shock d. Diabetes mellitus
A
At which of the following times should the nurse instill 15 to 30 mL of water with gastrostomy medication administration? (SATA) After each medication Before aspirating gastric contents When flow of medication by gravity slows Prior to administering each medication After giving multiple medications
After each medication, prior to administering each medication, after giving multiple medications
A nurse is collecting data from a client who is in the early stages of Hepatitis A. Which of the following manifestations should the nurse expect? a. Jaundice b. Anorexia c. Dark urine d. Pale feces
B
A nurse is collecting data from a client who is receiving chemotherapy and is showing manifestations of malnutrition. Which of the following indicates a Vitamin C deficiency? a. Dry, red conjuntiva b. Swollen, bleeding gums c. Inflammation of the tongue d. Pale, brittle nails
B
A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first? a. Measure stomach contents b. Flush tube with water c. Elevate HOB d. Return gastric content into the gastrostomy tube
C
The nurse is teaching a mother on how to take care of her child who is experiencing failure to thrive. The mother would not be correct in saying... a. I will feed the child slowly in a quiet area. b. I will burp the child frequently throughout the feeding. c. I will talk to the child in a loud and booming way so that he could be stimulated. d. I will carefully document food intake with caloric intake and strict I+O records
C
Where is water primarily absorbed?
Colon
A nurse is contributing to the plan of care for a client who acute pancreatitis. Which of the following interventions should the nurse include? a. Monitor peripheral pulses every 8 hours. b. Measure urinary output every 4 hours. c. Ambulate client tid. d. Maintain NPO status.
D
A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan? a. Change feeding bag and tubing every 72 hours. b. Keep head of bed elevated at 15 degrees. c. Place enough formula in the feeding bag to last for 8 hours of continuous feeding. d. Flush tube with 30 mL of water every 4 hours.
D
A nurse is turning on TPN therapy for a patient on their infusion pump. Which of the following should the nurse monitor for? a. Hypertension b. Excessive thirst c. Fever d. Diaphoresis
D
A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? a. Request a prescription for an oral formulation of the medication b. Administer the crushed medication through the NG tube c. Dissolve the medication in water and give it through NG tube d. Administer the medication under the client's tongue
D
The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a NG tube. Which of the following interventions should the nurse take when inserting the NG tube? a. Place client in a supine position. b. Measure the tube for insertion from the tip of the nose to the umbilicus. c. Withdraw the tube if the client gags during insertion. d. Instruct the client to place his chin to his chest and swallow.
D
A nurse is caring for a client with a h/x of pancreatitis. Which of the following food choices should the client avoid? a. Noodles b. Vegetable soup c. Baked fish d. Cheddar cheese
D (avoid foods high in fat)
What is the test doctors use to show any delays in development?
Denver Developmental Screening Test
What are the nursing considerations for a bolus tube feeding?
Elevate HOB 30 degrees and for at least 30 to 60 minutes following; administer feeding at room temperature; check for residual every 4 hours; daily weight;
What will the Hgb, BUN, creatinine, and Hct levels be when the patient has a bowel obstruction of any kind?
Elevated
What are the symptoms of acute pancreatitis?
Epigastric pain that may radiate to the back, that worsens when eating, eating high fat foods, or lying down; N&V; distended abdomen with hypoactive bowel sounds; ascites and tetany
How often should you change the IV bag and tubing for TPN?
Every 24 hours
What is Chvostek's sign?
Facial twitching when facial nerve is tapped; indicates hypocalcemia
What is ascites?
Fluid in the peritoneal cavity
Formulas for enteral feeding require what?
Functioning or partially functioning GI tract
A nurse is assisting with the care of a client who has a h/x of cirrhosis and is admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use? a. GGT b. ALP c. Serum bilirubin d. ALT
GGT
What will the bowel sounds be like with a mechanical bowel obstruction?
High pitched above and absent below
Medical t/x of acute pancreatitis
IV fluids, abx, pain medication
How long should a NG tube be in? A G-tube?
Less than 4 weeks; longer than 4 weeks
How many sounds a minute would be considered hypoactive bowel sounds?
Less than 5
What is the difference between a mechanical obstruction and a non-mechanical bowel obstruction?
Mechanical is when the flow is blocked, and non-mechanical is when peristalsis is absent
What acid balance disorder should monitor for a client with bowel obstructions?
Metabolic alkalosis
The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia? a. NG tube to suction b. Indwelling urinary catheter to gravity drainage c. Chest tube to water-seal drainage d. Nephrostomy tube to a drainage bag
NG tube to suction
S+S of chronic pancreatitis
Pain, weight loss, mild jaundice, dark urine; no lab elevation
What are the four part of the Denver Developmental Screening Test?
Personal/social; fine motor; language; gross motor
What is the role of the pancreas in digestion?
Produces enzymes that break down carbs, proteins, and fats
What are two labs that are indicated to confirm a d/x of acute pancreatitis?
Serum lipase and amylase
What's an ERCP?
Technique used to visualize pancreas, gallbladder, and bile ducts; treats complications of pancreatitis
What's the hallmark example of histamine receptor antagonists?
Zantac (ranitidine)
A nurse is reinforcing teaching with a client who has Barrett's esophagus and is scheduled to undergo an EGD. What statement should the nurse include in the teaching?
This procedure can determine how well the lower part of your esophagus works.
What is TPN?
Total parenteral nutrition that is delivered through a central line; needs to be titrated up and down
What is the hallmark example of pancreatic enzymes?
Viokase (pancrelipase)
What two things should be checked every 4 hours for someone on TPN?
Vital signs and blood glucose
A nurse is caring for a client who has celiac disease, and knows they should remove which of the following from the client's meal tray? a. Wheat toast b. Tapioca pudding c. Hard-boiled egg d. Mashed potatoes
a. Wheat toast
A nurse is reviewing medications for a client who has just been diagnosed with a small bowel obstruction. The nurse should withhold senna prescribed orally based on understanding of which of the following? a. Laxatives are contraindicated in clients who have small bowel obstructions b. Bulk-forming laxatives such as psyllium should be substituted for this client c. Prescribed medication should be administered via NG route rather than the oral route for this client d. Osmotic laxative, such as magnesium citrate, should be substituted in this client
A
A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place. Which of the following actions should the nurse include in the client's plan of care? (SATA) a. Perform leg exercises every 2 hours b. Encourage hourly use of IS while awake C. Document NG drainage characteristics and amount D. Irrigate NG every 4 to 8 hours E. Maintain best for 48 hours
A, B, C
What will the bowel sounds be like with a non-mechanical bowel obstruction?
Absent
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take? a. Flush tube with sterile sodium chloride solution every 2 hour b. Change feeding bag every 24 hours c. Check the gastric residual every 8 hours d. Position the head of client's bed at 15 degrees
B
A nurse is reinforcing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? a. You should decrease your caloric intake when abdominal pain is present b. You should increase your daily intake of protein c. You should increase fat intake when experiencing loose stools d. You should limit alcohol intake to 2 to 3 drinks per week
B
A nurse is reinforcing teaching about nutrition with the parent of a toddler. Which of the following statements should the nurse include in the teaching? a. Toddlers have increased appetites b. Toddlers have a decreased nutritional need c. Offer foods that are mixed together d. Fill plate with multiple food choices
B
A nurse is reinforcing teaching with a group of community residents about Hepatitis B. Which of the following statements should the nurse include in the teaching? a. Hep B recommended for those who travel b. Hep B immunization given to infants and children c. Hep B acquired by eating foods that are contaminated during handling d. Hep B can be prevented by using good personal hygiene habits and proper sanitation
B
In the first year of life, what happens to the infant?
Birth weight triples, length increases by 50%
Why do people with chronic pancreatitis lose weight, even when their appetite and eating habits are normal?
Body not secreting enough pancreatic enzymes to digest food, so nutrients are not absorbed like they should be
What will happen to glucose and WBC's levels during pancreatitis?
Both will be elevated
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take? a. Keep formula cold until instillation b. Withhold the feeding if the residual volume is 150 mL c. Cleanse the top of the can of formula with an alcohol wipe d. Flush tube with 30 mL of sterile water before the feeding
C
A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? a. Famotidine b. Esomeprazole c. Vasopressin d. Omeprazole
C
A nurse is caring for a client who has acute pancreatitis. Which lab value should the nurse anticipate returning to the expected reference range within 72 hours of treatment? a. Aldolase b. Lipase c. Amylase d. Lactic dehydrogenase
C
A nurse is collecting data from a client who is receiving intermittent enteral feedings. Which of the following lab values should the nurse identify as an indication that the client needs a change in the formula? a. Hematocrit 42% b. Urine specific gravity 1.022 c. BUN 28 mg/dL d. Sodium 142 mEq/L
C
A nurse is contributing to the plan of care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the plan of care? a. Provide frequent small snacks. b. Ambulate client bid. c. Monitor urine output hourly. d. Encourage deep breathing and coughing every 2 hours.
C
A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous GI decompression using an NG tube. Which of the following interventions should the nurse include in the plan of care? a. Measure abdominal girth daily. b. Use sterile water to irrigate. c. Maintain client in Fowler's position. d. Moisten lips with lemon-glycerin swabs.
C
A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include? a. Measure abdominal girth daily b. Provide bulk-forming agent c. Elevate head of bed d. Monitor intake and output every 8 hour
C
A nurse is reinforcing teaching about nutrition with a parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching? a. I should start solid foods when my baby is 3 months old b. I should introduce cow's milk when my baby is 9 months old c. I should wait to give my baby fruit juice until 6 months of age d. I should offer my baby well-cooked table foods at 8 months of age
C
A nurse is caring for a client who has a cognitive impairment and repeatedly pulls on his NG tube. Which of the following interventions should the nurse consider before requesting a prescription for restraints? (SATA) a. Explain restraints will be the next step. b. Assist with toileting at frequent intervals. c. Use an electronic position sensing device. d. Provide diversionary activities. e. Involve the family in the client's care.
C, D, E
A community health nurse is planning an educational program about hepatitis A. When preparing the materials, the nurse should identify that what age group is most at risk?
Children and young adults
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present, and should provide what at the initial feeding?
Clear liquids
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. Confirm placement of NG b. Remove gastric acid c. Determine client's electrolyte balance d. Identify delayed gastric emptying
D
A nurse is caring for a client who is postoperative and has a NG tube that has drained 2500 mL in the past 6 hours. The nurse should monitor for which of the following electrolyte imbalances?
Decreased potassium level
What is the most common cause of pancreatitis?
Gallstones; can also be caused by alcoholism
How many sounds a minute would be considered hyperactive bowel sounds?
Greater than 30
What is trousseau's sign?
Hand spams when BP cuff is inflated; indicates hypocalcemia
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
I will position the head of the bed 45 degrees during the feeding.
Med t/x for chronic pancreatitis
IV fluids; pain meds; pancreatic enzymes
Normal ranges for serum lipase and amylase
Lipase 0-160 Amylase >200
A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching? Vitamin A Vitamin B1 Vitamin C Vitamin B12
Vitamin A
