Chapter 43: Assessment of Digestive and Gastrointestinal Function

The nurse is instructing the client on frequent sensations experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common? A warm sensation Chills Light-headedness Heart palpitations

A warm sensation Explanation: The nurse informs the client that he or she may experience a warm sensation and nausea when the contrast agent is instilled. The client is instructed to take a couple of deep breaths, and, many times, the sensation will go away. The other options are not frequently encountered.

The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment? Thirst Drowsiness Sore throat Abdominal distention

Abdominal distention Explanation: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.

Which of the following is the primary function of the small intestine? Peristalsis Digestion Absorption Secretion

Absorption Explanation: Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.

The nurse is preparing the client for an assessment of the abdomen. What should the nurse complete prior to this assessment? Ask the client to empty the bladder. Prepare for a prostate examination. Dim the lights for privacy. Assist the client to a Fowler's position.

Ask the client to empty the bladder. Explanation: The physical examination of the gastrointestinal system includes assessment of the mouth, abdomen, and rectum. It requires good light, full exposure of the abdomen, warm hands with short nails, and a relaxed client with an empty bladder. A full bladder will interfere with inspection and may elicit discomfort with palpation and percussion, thereby altering results.

Which of the following is considered the gold standard for the diagnosis of liver disease? Cholecystography Paracentesis Biopsy Ultrasonography

Biopsy Explanation: Liver biopsy is considered the gold standard for the diagnosis of liver disease. Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Cholecystography and ultrasonography may be used to detect gallstones.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? Green Black Dark brown Red

Black Explanation: Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

During a colonoscopy with moderate sedation, the patient groans with obvious discomfort and begins bleeding from the rectum. The patient is diaphoretic and has an increase in abdominal girth from distention. What complication of this procedure is the nurse aware may be occurring? Rectal fissure Colonic polyp Bowel perforation Infection

Bowel perforation Explanation: Immediately after the test, the patient is monitored for signs and symptoms of bowel perforation (e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs).

When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important? Checking if the mucous membranes are dry Examining the sclera if it is yellow Observing for distended abdominal veins Checking if the skin is discolored

Checking if the mucous membranes are dry Explanation: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Computer tomography Upper GI series Colonoscopy Small bowel series

Colonoscopy Explanation: A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? Serve dairy products. Encourage plenty of fluids. Order a high-fiber diet. Serve the client his usual diet.

Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

Gastrin has which of the following effects on gastrointestinal (GI) motility? Increased motility of the stomach Relaxation of gastroesophageal sphincter Relaxation of the colon Contraction of the ileocecal sphincter

Increased motility of the stomach Explanation: Gastrin has the following effects on GI motility: increased motility of the stomach, excitation of the colon, relaxation of ileocecal sphincter, and contraction of the gastroesophageal sphincter.

When examining the abdomen of a client with reports of nausea and vomiting, what would the nurse do first? Palpation Percussion Auscultation Inspection

Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The health care provider begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption? Intrinsic factor Hydrochloric acid Liver enzyme Histamine

Intrinsic factor Explanation: Vitamin B12 absorption depends on intrinsic factor, which is secreted by parietal cells in the stomach. The vitamin binds with intrinsic factor and is absorbed in the ileum. Hydrochloric acid, histamine, and liver enzymes don't influence vitamin B12 absorption.

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated? Urinalysis Blood chemistry Complete blood count Liver function studies

Liver function studies Explanation: The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow? Monitoring the stool passage and its color. Observing the color of urine. Placing any stool passed in a specific preservative. Monitoring the volume of urine.

Monitoring the stool passage and its color. Explanation: Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A sigmoidoscopy A complete blood count including differential Gastric analysis Serum antibodies for H. pylori

Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.

After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? Liver Large Intestine Stomach Ileum

Stomach Explanation: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

A nurse is caring for a newly admitted patient with a suspected gastrointestinal (GI) bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. The nurse recognizes that the bleeding is likely occurring where? The lower GI tract The esophagus The anal area The upper GI tract

The upper GI tract Explanation: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

The nurse determines which is a true statement regarding older clients, considering the age-related effects on the gastrointestinal (GI) system? They have no awareness of the filling reflex. They tend to have higher physiologic reserves to compensate for fluid loss. They tend to have increased muscle tone and mass. They usually have less control of the rectal sphincter.

They usually have less control of the rectal sphincter. Explanation: Older adults tend to have fewer physiologic reserves to compensate for fluid loss. The older adult usually has less control of the rectal sphincter than a younger adult because of age-related changes in innervations, a diminished awareness of the filling reflex, and decreased muscle tone.

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system? duodenum ileum jejunum cecum

duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are hypoactive. absent. normal. sluggish.

normal. Explanation: Normal bowel sounds are heard every 5 to 20 seconds. Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Sluggish is not a term a nurse would use to accurately describe bowel sounds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? "I'll drink full liquids the day before the test." "I'll take a laxative to clear my bowels before the test." "There is no need for special preparation before the test." "I'll avoid eating or drinking anything 6 to 8 hours before the test."

"I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

Upon hearing that the small intestine lining has thinned, an elderly client asks, "What can this lead to?" What is the best response by the nurse? "At times you may see mucus in your stool." "You may frequently have diarrhea." "You may frequently experience constipation." "It is the aging process."

"You may frequently experience constipation." Explanation: As a person ages, the epithelial cells and villi thin in the small intestine. Implications of this consequence include decreased intestinal motility and transit time, which can lead to constipation. This would lead the nurse to discuss and advise the client on ways to prevent constipation.

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first? Further investigate the initial complaint. Explain that fatty foods can mimic chest pain. Administer an over-the-counter antacid tablet. Call for an immediate electrocardiogram.

Further investigate the initial complaint. Explanation: While fatty foods can cause discomfort similar to chest pain, the nurse must fully assess all the client's symptoms. Investigation of chief complaint begins with a complete history. The underlying cause of pain influences the characteristics, duration, pattern, location, and distribution of pain.

The nurse is working with clients with digestive tract disorders. Which of the following organs does the nurse realize has effects as an exocrine gland and an endocrine gland? Gallbladder Liver Pancreas Stomach

Pancreas Explanation: The pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions? Atropine Glycopyrronium bromide Pentagastrin Acetylcysteine

Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.

Which of the following is an enzyme secreted by the gastric mucosa? Trypsin Bile Ptyalin Pepsin

Pepsin Explanation: Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.

Following ingestion of carrots or beets, the nurse would expect which alteration in stool color? Yellow Black Milky white Red

Red Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Left Sim's lateral Lithotomy Knee-chest Supine with knees flexed

Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

While completing an abdominal assessment, the nurse will use which landmark as the upper boundary for auscultating bowel sounds? Umbilicus Xiphoid process Symphysis pubis T12 to L3 vertebrae

Xiphoid process Explanation: Understanding the division of the abdomen into four quadrants or nine regions helps the nurse to complete thorough assessment. The xiphoid process in the epigastric region is the upper boundary for auscultating bowel sounds.

The nurse prepares a client for a barium enema. The nurse should place the client on which diet prior to the procedure? soft diet 1 day prior nothing by mouth (NPO) 2 days prior high-fiber diet 1 to 2 days prior clear liquids day before

clear liquids day before Explanation: The nurse should place the client on clear liquids the evening before the procedure, a low-residue diet 1 to 2 days before the test, and NPO at midnight in preparation for the barium enema.

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? chronic atrophic gastritis gastric cancer duodenal ulcer pernicious anemia

duodenal ulcer Explanation: Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.

The major carbohydrate that tissue cells use as fuel is glucose. chyme. proteins. fats.

glucose. Explanation: Glucose is the major carbohydrate that tissue cells use as fuel. Proteins are a source of energy after they are broken down into amino acids and peptides. Chyme stays in the small intestine for 3 to 6 hours, allowing for continued breakdown and absorption of nutrients. Ingested fats become monoglycerides and fatty acids by the process of emulsification.

Which response is a parasympathetic response in the GI tract? increased peristalsis decreased motility decreased gastric secretion blood vessel constriction

increased peristalsis Explanation: Increased peristalsis is a parasympathetic response in the GI tract. Decreased gastric secretion, blood vessel constriction, and decreased motility are sympathetic responses in the GI tract.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for recent foods ingested. pilonidal cyst. occult blood. ingestion of bismuth.

recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.

A client presented with gastrointestinal bleeding 2 days ago and continues to have problems. The health care provider has ordered a visualization of the small intestine via a capsule endoscopy. What will the nurse include in the client education about this procedure? "A capsule will be inserted into your rectum." "An x-ray machine will use a capsule ray to follow your intestinal tract." "The health care provider will use a scope called a capsule to view your intestine." "You will need to swallow a capsule."

"You will need to swallow a capsule." Explanation: A capsule endoscopy allows for noninvasive visualization of the small intestinal mucosa. The technique consists of the client swallowing a capsule that is embedded with a wireless miniature camera, which is propelled through the intestine by peristalsis. The capsule passes from the rectum in 1 to 2 days.

Which procedure is performed to examine and visualize the lumen of the small bowel? peritoneoscopy small bowel enteroscopy panendoscopy colonoscopy

small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It detects a protein normally found in the blood." "It indicates if a cancer is present." "It determines functionality of the liver." "It tells the physician what type of cancer is present."

"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response? stomach rectum small intestine large intestine

small intestine Explanation: The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.

The nurse recognizes which change of the GI system is an age-related change? weakened gag reflex increased mucus secretion increased motility hypertrophy of the small intestine

weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? Hypoactive Borborygmi Hyperactive Normal

Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).

The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? Use all options. Percussion Auscultation Inspection Palpation

Inspection Auscultation Percussion Palpation Explanation: The nurse is correct to assess the abdomen in a specific order to be able to judge the undisturbed status of the abdominal region. Begin with inspection of the abdomen using the nurse's assessment skills. Next, auscultate the abdomen before percussing and finally palpating.

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location? Duodenum Ileum Cecum Sigmoid colon

Sigmoid colon Explanation: Water is reabsorbed by means of diffusion across the intestinal membrane as the contents move through the colon. By the time the mixture reaches the descending and sigmoid colon, the portion of the bowel adjacent to the rectum, it is a formed mass. The ileum and duodenum are located in the small intestine. The cecum is located at the beginning of the large intestine.

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon returning to the nursing unit, what does the nurse identify as the client goal? Decrease in nausea and vomiting Increase in the amount of fluids Recovery from the general anesthesia Ambulates independently

Increase in the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? Instruct the client to have low-residue meals. Allow the client to ingest fat-free meal. Provide saline gargles to the client. Permit the client to drink only clear liquids.

Permit the client to drink only clear liquids. Explanation: After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.

Which nursing instruction is correct to provide the client following a barium enema? An enema will be used to clear the bowel. The client will maintain a low residue diet. The stools may be a white or clay colored. Sips of fluid may be increased if tolerated.

The stools may be a white or clay colored. Explanation: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? Both tests need to be done before breakfast. The client may eat a light meal before either test. The ultrasonography should be scheduled before the GI procedure. The upper GI should be scheduled before the ultrasonography.

The ultrasonography should be scheduled before the GI procedure. Explanation: Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia? Increase in bile secretion Decrease in intestinal flora Atrophy of the gastric mucosa Dulling of nerve impulses

Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.

The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." "It is not going to happen. Your nerve cells are too damaged." "Wearing an undergarment will become more comfortable over time." "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again."

"Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." Explanation: The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.

After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. What should the nurse do based on the assessment findings? Listen longer for the sounds. Return in 1 hour and listen again to confirm findings. Call the health care provider to report absent bowel sounds. Document that the client is constipated.

Listen longer for the sounds. Explanation: Auscultation is used to determine the character, location, and frequency of bowel sounds. The frequency and character of sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minutes. Normal sounds are heard about every 5 to 20 seconds, whereas hypoactive sounds can be one or two sounds in 2 minutes. Postoperatively, it is common for sounds to be reduced; therefore, the nurse needs to listen at least 3 to 5 minutes to verify absent or no bowel sounds.

The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes being ashamed because he is having frequent gas. Which nursing suggestion is best? "Do not be ashamed. Everyone has gas following the procedure." "The nursing staff is used to having clients with gas due to the procedure completed." "Having gas following the procedure is normal. Expel the gas to decrease discomfort." "Nurses anticipate that client will have gas following the procedure and provide privacy."

"Having gas following the procedure is normal. Expel the gas to decrease discomfort." Explanation: The nurse is correct to tell the client that what he is experiencing is normal and encourage the client to release the gas to decrease pain and discomfort. Proving information relieving the embarrassment and stating the benefit of the action is most helpful.

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss? "You must remove all jewelry but can wear your wedding ring." "You must be NPO for the day before the examination." "Do you experience any claustrophobia?" "The examination will take only 15 minutes."

"Do you experience any claustrophobia?" Explanation: MRI is a noninvasive technique that uses magnetic fields and radio waves to produce images of the area being studied. Clients must be NPO for 6 to 8 hours before the study and remove all jewelry and other metals. The examination takes 60 to 90 minutes and can induce feelings of claustrophobia, because the scanner is close fitting.

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? Take vitamin K before the procedure. Take three cleansing enemas before the procedure. Avoid the intake of red meat before the procedure. Avoid smoking for at least 12 to 24 hours before the procedure.

Avoid smoking for at least 12 to 24 hours before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.

The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure? Spray or gargle with a local anesthetic. Do not void for at least 30 minutes before the test. Consume at least 3 quarts of water 30 minutes before the test. Follow the dietary and fluid restrictions and bowel preparation procedures.

Follow the dietary and fluid restrictions and bowel preparation procedures. Explanation: For a client due to have a colonoscopy, it is essential that the client follow the dietary and fluid restrictions and bowel preparation procedures. For the client having an esophagogastroduodenoscopy (EGD), it is necessary for the client to spray or gargle with a local anesthetic. The client is not advised to consume 3 quarts of water nor to void before the test. These interventions may be essential for tests that involve ultrasonographic procedures.

Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances? Magnetic resonance imaging (MRI) Computed tomography (CT) Positron emission tomography (PET) Fibroscopy

Positron emission tomography (PET) Explanation: PET produces images of the body by detecting the radiation emitted from radioactive substances. CT provides cross-sectional images of abdominal organs and structures. MRI uses magnetic fields and radio waves to produce an image of the area being studied. Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted endoscope.

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? Prothrombin time (PT) Erythrocyte sedimentation rate (ESR) Blood chemistry Complete blood count (CBC)

Prothrombin time (PT) Explanation: The client must have coagulation studies before the procedure such as a PT or PTT because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition? congestive heart failure chronic obstructive pulmonary disease inflammatory bowel disease pulmonary hypertension

inflammatory bowel disease Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.

The nurse is assisting the physician in a percutaneous liver biopsy. In assisting with positioning, the nurse should assist the client into a: high Fowler's position. dorsal recumbent position. lithotomy position. supine position.

supine position. Explanation: The nurse is correct to instruct the client to assume the supine position. Also, the nurse places a rolled towel beneath the right lower ribs.