Chapter 44
Which of the following should the nurse complete prior to assessing the abdomen of a 35-year-old man? a) Prepare for a prostate examination. b) Dim the lights for privacy. c) Ask the client to empty his bladder. d) Assist the client to a Fowler's position.
Ask the client to empty his bladder. Correct 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. 1202
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? a) Rectal fissure b) Colonic polyp c) Bowel perforation d) Infection
Bowel perforation Correct 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).1210
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids? a) Colonoscopy b) Sigmoidoscopy c) Peritoneoscopy d) Esophagogastroduodenoscopy
Esophagogastroduodenoscopy Correct Explanation: The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.1208-9
The nurse is assessing bowel sounds and hears one to two bowel sounds in 2 minutes. The nurse documents the bowel sounds as being which of the following? a) Hypoactive b) Hyperactive c) Absent d) Normal
Hypoactive Correct Explanation: Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when five or six sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.1202
Gastrin has which of the following effects on gastrointestinal (GI) motility? a) Contraction of the ileocecal sphincter b) Relaxation of gastroesophageal sphincter c) Relaxation of the colon d) Increased motility of the stomach
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.1199
When examining the abdomen of a client with complaints of nausea and vomiting, which of the following would the nurse do first? a) Inspection b) Palpation c) Percussion d) Auscultation
Inspection Correct Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
Which diagnostic produces images of the body by detecting the radiation emitted from radioactive substances? a) Fibroscopy b) Computed tomography (CT) c) Positron emission tomography (PET) d) Magnetic resonance imaging (MRI)
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. 1207
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? a) Ileum b) Liver c) Large intestine d) Stomach
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.1197
The nurse is assisting the physician with a colonoscopy for a patient with rectal bleeding. The physician requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure? a) To reduce air accumulation in the colon. b) To relieve anxiety during the procedure for moderate sedation. c) To relax colonic musculature and reduce spasm. d) The patient is probably hypoglycemic and requires the glucagon.
To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.1210
When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are a) sluggish. b) normal. c) absent. d) hypoactive.
normal. Correct 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. 1203
The nurse is a preparing a patient for a barium enema. The nurse should place the patient on which of the following prior to the procedure? a) Soft diet 1 day prior b) High-fiber diet 1 to 2 days prior c) Clear liquids day before d) Nothing by mouth (NPO) 2 days prior
Clear liquids day before Explanation: The nurse should place the patient 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. 1207
A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? a) Serve dairy products. b) Serve the client his usual diet. c) Encourage plenty of fluids. d) Order a high-fiber diet.
Encourage plenty of fluids. Correct 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. 1206
Which of the following is an enzyme secreted by the gastric mucosa? a) Bile b) Pepsin c) Trypsin d) Ptyalin
Pepsin Correct 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.1198
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? a) Metabolic acidosis and hyperkalemia b) Metabolic alkalosis and hypokalemia c) Metabolic acidosis and hypokalemia d) Metabolic alkalosis and hyperkalemia
Metabolic alkalosis and hypokalemia Correct Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia. 1201
The nurse is assisting the physician with a gastric acid stimulation test for a patient. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions? a) Atropine b) Pentagastrin c) Mucomyst d) Robinul (glycopyrrolate)
Pentagastrin Correct Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions. 1212
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? a) Allow the client to ingest fat-free meal. b) Permit the client to drink only clear liquids. c) Provide saline gargles to the client. d) Instruct the client to have low-residue meals.
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. 1210
The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? a) Complete blood count (CBC) b) Erythrocyte sedimentation rate (ESR) c) Blood chemistry d) Prothrombin time (PT)
Prothrombin time (PT) Correct 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. 1343
Using gastric analysis, the nurse would expect that a patient diagnosed with peptic ulcer would secrete which of the following? a) An excess amount of acid b) No acid under basal condition or after stimulation c) Small amount of acid d) Little or no acid
Small amount of acid Explanation: Patient with peptic ulcer disease secrete some acid. Patients with gastric cancer secrete little or no acid. Patients with duodenal ulcers secrete an excess amount of acid. Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.1212
A client receives a local anesthetic to suppress the gag reflex for a diagnostic procedure of the upper GI tract. Which of the following nursing interventions is advised for this patient? a) The client should be monitored for cramping or abdominal distention. b) The client's fluid output should be measured for at least 24 hours after the procedure. c) The client should be monitored for any breathing-related disorder or discomforts. d) The client should not be given any food and fluids until the gag reflex returns.
The client should not be given any food and fluids until the gag reflex returns. Correct Explanation: For a client receiving a local anesthetic that suppresses the gag reflex, the nurse is advised to withhold food and fluids until the reflex returns. The nurse is advised to withhold food and fluids until the reflex returns.1209
Upon review of a client's chart, the nurse notes the client has been receiving antiemetics every 6 to 8 hours. What in this client's history may necessitate such frequency? a) Treatment for cancer b) Pituitary tumor c) Multiple leg fractures d) Adrenal gland removal 3 days ago
Treatment for cancer Correct Explanation: Antiemetics are used to treat nausea and vomiting. Common causes of nausea and vomiting include visceral afferent stimulation, peritoneal irritation, infections, radiation or chemotherapy therapy, increased intracranial pressure, and vestibular disorders. Irritation of the chemoreceptor trigger zone from cancer treatment can induce nausea and lead to vomiting. 1201
Which of the following is an age-related change of the GI system? a) Hypertrophy of the small intestine b) Increased mucus secretion c) Weakened gag reflex d) Increased motility
Weakened gag reflex Correct 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. 1200
During Mrs. Feldman's physical assessment, she informs you that her stools have been red lately. Which of the following will the nurse include in her assessment questioning? a) "Have you been eating spinach?" b) "Have you been taking an iron supplement?" c) "Have you been eating beets?" d) "Have you been drinking grape juice?"
"Have you been eating beets?" Correct Explanation: Foods and medications can alter the color of stool. Beets will often change the color of stool to red.
Which of the following digestive enzymes aids in the digesting of starch? a) Lipase b) Trypsin c) Amylase d) Bile
Amylase Correct Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch; and lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme. 1198
A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? a) Occult bleeding b) Cancer screening c) Inflammatory bowel disease d) Bowel disease of unknown origin
Cancer screening Correct Explanation: This procedure is used commonly as a diagnostic aid and screening device. It is most frequently used for cancer screening and for surveillance in patients with previous colon cancer or polyps. In addition, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. Other uses of colonoscopy include the evaluation of patients with diarrhea of unknown cause, occult bleeding, or anemia; further study of abnormalities detected on barium enema; and diagnosis, clarification, and determination of the extent of inflammatory or other bowel disease.1209
When gastric analysis testing reveals excess secretion of gastric acid, which of the following medical diagnoses is supported? a) Pernicious anemia b) Duodenal ulcer c) Chronic atrophic gastritis d) Gastric cancer
Duodenal ulcer Explanation: Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Patients with chronic atrophic gastritis secrete little or no acid. Patients with gastric cancer secrete little or no acid. Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.1211-1212
The nurse is caring for a patient who complains of abdominal bloating, distention, and feeling full of gas. These could be symptoms of which of the following? a) Dyspepsia b) Small bowel obstruction c) Food allergy d) Rectal cancer
Food allergy Explanation: A patient with a food allergy complains of abdominal bloating, distention, and feeling full of gas. These are not symptoms related to small bowel obstruction or rectal cancer. Dyspepsia is abdominal discomfort associated with eating. 1101
Which of the following terms describes a gastric secretion that combines with vitamin B12 so that it can be absorbed? a) Intrinsic factor b) Pepsin c) Trypsin d) Amylase
Intrinsic factor Correct Explanation: Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12 cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein. 1198
The nurse is assessing a client who is stating gastrointestinal upset and a feeling of bloating. Which type of meal would the nurse anticipate causing these types of symptoms? a) Hamburger and French fries b) Grilled chicken on a spinach salad c) Salmon with cheddar mashed potatoes d) Steamed rice with pork and broccoli
Hamburger and French fries Correct Explanation: Fatty foods delay stomach emptying (bloating) and can cause symptoms of gastrointestinal upset. Fried and deep fried foods contain elevated amounts of fat. The other options have a lower fat content. 1201
The nurse has been directed to position a patient for an examination of the abdomen. What position should the nurse place the patient in for the examination? a) Prone position with pillows positioned to alleviate pressure on the abdomen b) Reverse Trendelenburg position to facilitate the natural propulsion of intestinal contents c) Semi-Fowler's position with the left leg bent to minimize pressure on the abdomen d) Supine position with the knees flexed to relax the abdominal muscles
Supine position with the knees flexed to relax the abdominal muscles Correct Explanation: The patient lies supine with knees flexed slightly for inspection, auscultation, percussion, and palpation of the abdomen.1202
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? a) Normal b) Hyperactive c) Borborygmi d) Hypoactive
Hyperactive Correct 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). 1203
After 20 seconds of auscultating for bowel sounds on a client recovering from abdominal surgery, the nurse hears nothing. Which of the following should the nurse do based on the assessment findings? a) Call the physician to report absent bowel sounds. b) Listen longer for the sounds. c) Return in 1 hour and listen again to confirm findings. d) Document that the client is constipated.
Listen longer for the sounds. Correct 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. 1203
A nursing instructor tells the class that review of oral hygiene is an important component during assessment of the gastrointestinal system. One of the students questions this statement. Which of the following explanations from the nurse educator is most appropriate? a) "Bad breath will encourage ingestion of fatty foods to mask odor." b) "Decaying teeth secrete toxins that decrease the absorption of nutrients." c) "Injury to oral mucosa or tooth decay can lead to difficulty in chewing food." d) "Mouth sores are caused by bacteria that can thin the villi of the small intestine."
"Injury to oral mucosa or tooth decay can lead to difficulty in chewing food." Correct Explanation: Poor oral hygiene can result in injury to the oral mucosa, lip, or palate; tooth decay; or loss of teeth. Such problems may lead to disruption in the digestive system. The ability to chew food or even swallow may be hindered. 1202
A client is scheduled for several diagnostic tests to evaluate her gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when she identifies which test as not requiring the use of a contrast medium? a) Small bowel series b) Computer tomography c) Colonoscopy d) Upper GI 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. 1209
The nurse is performing an assessment of a patient. During the assessment the patient informs the nurse of some recent "stomach trouble." What does the nurse know is the most common symptom of patients with GI dysfunction? a) Abdominal bloating b) Constipation c) Diffuse pain d) Dyspepsia
Dyspepsia Explanation: Dyspepsia, upper abdominal discomfort associated with eating (commonly called indigestion), is the most common symptom of patients with GI dysfunction. Indigestion is an imprecise term that refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation; it occurs in approximately 25% of the adult population (Harmon & Peura, 2010). 1201
The nurse is investigating a patient's complaint of pain in the duodenal area. Where should the nurse perform the assessment? a) Periumbilical area, followed by the right lower quadrant b) Left lower quadrant c) Epigastric area and consider possible radiation of pain to the right subscapular region d) Hypogastrium in the right or left lower quadrant
Epigastric area and consider possible radiation of pain to the right subscapular region Explanation: Indigestion is an imprecise term that refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation; it occurs in approximately 25% of the adult population (Harmon & Peura, 2010).1201
Which of the following should be included as part of the preprocedure teaching for a patient scheduled for a proctosigmoidoscopy involving the lower GI structures? a) Consume at least three quarts of water 30 minutes before the test b) Follow the dietary and fluid restrictions and bowel preparation procedures c) Do not void for at least 30 minutes before the test d) Spray or gargle with a local anesthetic
Follow the dietary and fluid restrictions and bowel preparation procedures Correct Explanation: For a patient due to undergo a proctosigmoidoscopy, it is essential that the patient follows the dietary and fluid restrictions and bowel preparation procedures if the examination involves the lower GI structures. For the patient undergoing an esophagogastroduodenoscopy (EGD), it is necessary for the patient to spray or gargle with a local anesthetic. The patient is not advised to consume three quarts of water and is not advised to void before the test. These interventions may be essential for tests that involve ultrasonographic procedures. 1207
From the following profiles of clients, which client would be most likely to undergo the diagnostic test of cholecystography? a) Steven, suspected of having a tumor in the colon b) Andrew, suspected of having esophageal abnormalities c) Sandra, suspected of having lesions in the liver d) Mark, suspected of having stones in the gallbladder
Mark, suspected of having stones in the gallbladder Explanation: Cholecystography will be most appropriate for Mark because the test is used to detect stones in the gallbladder. Most likely, Andrew would require barium swallow test to detect any abnormalities in the esophagus. Steven would need a barium enema for to identify a tumor in the colon. Sandra would undergo a radionuclide image test for her lesions in the liver. 1389
A patient tells the nurse that his stool was colored yellow. The nurse assesses for which of the following? a) Occult blood b) Ingestion of bismuth c) Pilonidal cyst d) Recent foods ingested
Recent foods ingested Correct Explanation: The nurse should assess for recent foods that the patient 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.1201
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) Serum antibodies for H. pylori b) A complete blood count including differential c) Gastric analysis d) A sigmoidoscopy
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.1262
Which patient teaching component is important for the nurse to communicate regarding pain management prior to or during diagnostic testing for a disorder of the GI system? a) The patient should take a sedative before the procedure to avoid the possibility of experiencing any discomfort. b) The patient should inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids. c) The patient should not expel gas and test fluids from the bowel when he or she experiences the urge during the procedure. d) The patient should lie down in a supine position for at least 3 hours before the test to reduce any discomfort during the test.
The patient should inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids. Correct Explanation: To ensure that a patient who is to undergo a diagnostic test for a disorder of the gastrointestinal system experiences no or minimal discomfort during the test, the patient should be instructed to inform the test personnel if he or she experiences pressure or cramping during the instillation of test fluids. The test personnel can slow the instillation or take other measures to relieve discomfort. The patient should also be advised to expel gas and test fluids from the bowel when he or she experiences the urge. Ignoring the urge to expel the bowel contents increases pain and discomfort. The patient should be advised not to take any sedative or analgesic before the test, unless prescribed. Lying down in a supine position is not known to have any consequence on the level of discomfort experienced by a patient during a diagnostic test for a GI disorder.1206
Which nursing instruction is correct to provide the client following a barium enema? a) An enema will be used to clear the bowel. b) The client will maintain a low residue diet. c) Sips of fluid may be increased if tolerated. d) The stools may be a white or clay colored.
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. 1201
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? a) The client may eat a light meal before either test. b) Both tests need to be done before breakfast. c) The upper GI should be scheduled before the ultrasonography. d) The ultrasonography should be scheduled before the GI procedure.
The ultrasonography should be scheduled before the GI procedure. Correct 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. 1205
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is: a) "Is your partner being treated for tuberculosis?" b) "Has your partner recently fallen or injured his chest?" c) "Has your partner had recent forceful vomiting?" d) "What spices and condiments does your spouse use on food?"
"Has your partner had recent forceful vomiting?" Explanation: A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between forceful vomiting, and a Mallory-Weiss tear. The bleeding is coming from the stomach, not from the lungs as would be true in some cases of tuberculosis. A Mallory-Weiss tear doesn't occur from chest injuries or falls and isn't associated with eating spicy foods.984
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician? a) "I haven't had anything to eat or drink since midnight last night." b) "I brought earphones to shut out the loud noise." c) "I really don't like to be in small, enclosed spaces." d) "I left all my jewelry and my watch at home."
"I really don't like to be in small, enclosed spaces." Correct Explanation: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful. 1207
The nurse is educating a patient about to undergo hydrogen breath testing about the test. The nurse evaluates that the patient understands the test when he states which of the following? a) "First I will drink a cherry flavored liquid." b) "The test will detect the presence of staph." c) "I should avoid antibiotics for 1 month before the test." d) "The test will detect the presence of oral cancer."
"I should avoid antibiotics for 1 month before the test." Explanation: The nurse evaluates that the patient understands the education when he states that he should avoid antibiotics one month before the test. In addition the patient should avoid loperamide (Pepto Bismol), sucralfate (Carafate), and omeprazole (Prilosec) for 1 week prior to the test, and cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac) for 24 hours before the test. During the test, the patient swallows a capsule of carbon-labeled urea and a breath sample is obtained 10 to 20 minutes later. The hydrogen breath test detects the presence of Helicobacter pylori, the bacteria that causes peptic ulcer disease.1204
A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching? a) "I should limit my fiber intake for 1 to 2 weeks following the procedure." b) "I should report when I have a bowel movement." c) "I won't need a laxative after the procedure." d) "I should increase my fluid intake to 2,000 to 3,000 ml/day."
"I should limit my fiber intake for 1 to 2 weeks following the procedure." Correct Explanation: There's no need to limit fiber intake after a barium enema. The client may resume his normal diet. Barium may increase stool elimination, so there's no need for a laxative after the procedure. The client should increase fluid intake to facilitate barium elimination. The client should report bowel movements so the nurse can ensure that barium elimination occurs. 1207
A patient asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: a) "It tells the physician what type of cancer is present." b) "It determines functionality of the liver." c) "It detects a protein normally found in the blood." d) "It indicates if a cancer is present."
"It indicates if a cancer is present." Explanation: The CEA blood test detects the presence of cancer by detecting 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. 1204
Which of the following is a parasympathetic response in the GI tract? a) Increased peristalsis b) Decreased gastric secretion c) Blood vessel constriction d) Decreased motility
Increased peristalsis Correct 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 presented with gastrointestinal bleeding 2 days ago and continues to have problems. The physician has ordered a visualization of the small intestine via a capsule endoscopy. Which of the following will the nurse include in the client education about this procedure? a) "A capsule will be inserted into your rectum." b) "An x-ray machine will use a capsule ray to follow your intestinal tract." c) "You will need to swallow a capsule." d) "The physician will use a scope called a capsule to view your intestine."
"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. 1211
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment? a) Drowsiness b) Abdominal distention c) Thirst d) Sore throat
Abdominal distention Correct 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. 1209
When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? a) Take vitamin K before the procedure. b) Avoid the intake of red meat before the procedure. c) Take three cleansing enemas before the procedure. d) Avoid smoking for at least 12 to 24 hours before the procedure.
Avoid smoking for at least 12 to 24 hoursbefore 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.1206
Which of the following is considered the gold standard for the diagnosis of liver disease? a) Cholecystography b) Ultrasonography c) Paracentesis d) Biopsy
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. 1212
The hydrogen breath test was developed to evaluate which type of absorption? a) Fat b) Carbohydrate c) Vitamin B12 d) Protein
Carbohydrate Correct Explanation: The hydrogen breath test that is used to evaluate carbohydrate absorption is performed if carbohydrate malabsorption is suspected. The hydrogen test does not evaluate fat, protein, or vitamin B12 absorption. 1204
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? a) Administer an over-the-counter antacid tablet. b) Call for an immediate electrocardiogram. c) Explain that fatty foods can mimic chest pain. d) Further investigate the initial complaint.
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.1201
What part of the GI tract begins the digestion of food? a) Esophagus b) Mouth c) Stomach d) Duodenum
Mouth Correct Explanation: Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth. 1197
What part of the GI tract begins the digestion of food? a) Duodenum b) Esophagus c) Mouth d) Stomach
Mouth Correct Explanation: Food that contains starch undergoes partial digestion in the mouth when it mixes with the enzyme salivary amylase, which the salivary glands secrete. Food that contains starch undergoes partial digestion in the mouth.1197
A nurse is providing postprocedure instructions for a client who had an esophagogastroduodenoscopy. The nurse should perform which action? a) Tell the client to call back in the morning so she can give him instructions over the phone. b) Review the instructions with the person accompanying the client home. c) Give instructions to the client immediately before discharge. d) Tell the client there aren't specific instructions for after the procedure.
Review the instructions with the person accompanying the client home. Correct Explanation: A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and his memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions to the person who is accompanying the client home. It isn't appropriate for the nurse to tell the client to call back in the morning for instructions. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician. 1209
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? a) "It is not going to happen. Your nerve cells are too damaged." b) "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." c) "Wearing an undergarment will become more comfortable over time." d) "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact."
"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. 1200
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a) "There is no need for special preparation before the test." b) "I'll take a laxative to clear my bowels before the test." c) "I'll avoid eating or drinking anything 6 to 8 hours before the test." d) "I'll drink full liquids the day before the test."
"I'll avoid eating or drinking anything 6 to 8 hours before the test." Correct Explanation: The client demonstrates understanding of a barium swallow when he states that he 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. 1206
Which of the following is the primary function of the small intestine? a) Secretion b) Absorption c) Digestion d) Peristalsis
Absorption Correct Explanation: Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes. 1197
Which of the following neuroregulators increase gastric acid secretion? a) Gastrin b) Acetylcholine c) Secretin d) Norepinephrine
Acetylcholine Explanation: Acetylcholine causes increased gastric acid. Norepinephrine inhibits secretions of the GI tract. Gastrin increases secretion of gastric juice, which is rich in HCL. Secretin in the stomach inhibits gastric secretion somewhat.1199
A nurse assesses the abdomen of a newly admitted client. Which finding would necessitate further investigation? a) Rounded contour b) Flat appearance below the umbilicus c) Striae of lateral abdomen d) Asymmetrical upper quadrants
Asymmetrical upper quadrants Correct Explanation: The client lies supine with knees flexed for the abdominal assessment. Upon inspection the nurse notes any skin changes, nodules, lesions, inflammation, or striae. Lesions are of particular importance and require further investigation, as do irregular contours or asymmetry of the abdomen. 1203
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia? a) Dulling of nerve impulses b) Increase in bile secretion c) Decrease in intestinal flora d) Atrophy of the gastric mucosa
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. 1200
Swallowing is regulated by which area of the central nervous system (CNS)? a) Medulla oblongata b) Pons c) Hypothalamus d) Cerebellum
Medulla oblongata Explanation: Swallowing begins as a voluntary act that is regulated by the swallowing center in the medulla oblongata of the CNS. The act of swallowing requires the innervations of five cranial nerves (CNs), especially CN V, VII, IX, X, and XII. Swallowing is not regulated by the pons, cerebellum, or hypothalamus. 1198
Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow? a) Observing the color of urine. b) Placing any stool passed in a specific preservative. c) Monitoring the volume of urine. d) Monitoring the stool passage and its color.
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. 1207
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color? a) Yellow b) Red c) Black d) Milky white
Red Correct 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. 1201
The nurse preparing a patient for a colostomy is preparing to administer the lavage solution. The nurse stops and notifies the physician when the nurse notes that the patient has which of the following? a) Inflammatory bowel disease b) Chronic obstructive pulmonary disease (COPD) c) Pulmonary hypertension d) Congestive heart failure
Inflammatory bowel disease Correct Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the patient has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. COPD, congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.1210
The nurse is inspecting a patient's tongue. Which of the following findings would the nurse evaluate as an indication of potential oral cancer? a) Thin, white coating on dorsum of tongue b) Large, vallate papillae on dorsum of tongue c) Red plaque on undersurface of tongue d) V formation on dorsum of tongue
Red plaque on undersurface of tongue Explanation: Red or white plaque located on the undersurface of the tongue can be indicative of oral cancer. A thin, white coating on the dorsum of the tongue and large vallate papillae that form a V on the distal portion of the tongue are normal findings. 1202
The nurse is talking with a client who is scheduled for a computed tomography (CT) colonography. Which client statement would indicate to the nurse that the client needs additional teaching about this procedure? a) "I won't need any sedation for this procedure." b) "My doctor will be able to remove any polyps he finds." c) "The risk for complications is less than a regular colonoscopy." d) "I still need to do that all that bowel prep stuff."
"My doctor will be able to remove any polyps he finds." Correct Explanation: With a computed tomography (CT) colonography, other procedures such as polyp removal or biopsy cannot be done. It requires the same preparation as a colonoscopy, but sedation is not required. In addition, there is less risk of bowel perforation. 1209
A patient is in the outpatient recovery area after having a colonoscopy and informs the nurse of abdominal cramping. What is the best response by the nurse? a) "I will call the physician and let him know. He may have put too much air in your colon." b) "We may need to go back in and see what is wrong. You shouldn't have discomfort." c) "The cramping is caused by the air insufflated in the colon during the procedure." d) "I will call the physician and see if I can give you pain medication. Sometimes the pain can be caused by having a biopsy."
"The cramping is caused by the air insufflated in the colon during the procedure." Explanation: Some patients have abdominal cramps caused by increased peristalsis stimulated by the air insufflated into the bowel during the procedure.1210
The nurse is assessing a client following laparoscopy. The client states that his stomach looks bloated and asks if this is normal. How will the nurse respond? a) "Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization." b) "Do you need to use the restroom? You may have to have a bowel movement." c) "No, this should not occur. I will call the physician right away." d) "I am not sure about this. Let me get another nurse."
"Yes, your abdomen may appear larger as a result of the injection of carbon dioxide for visualization." Correct Explanation: During a laparoscopic procedure, a pneumoperitoneum is used to inject carbon dioxide into the peritoneal cavity to separate the intestines from the pelvic organs. Gas (carbon dioxide) is insufflated into the peritoneal cavity to create a working space for visualization. 1212
A client who had a colonoscopy with removal of a polyp is being prepared for discharge. Which of the following would the nurse include in the discharge instructions? a) "You might experience some nausea and vomiting for a day or so. This is normal." b) "You might feel some cramping and gas but these usually go away in about a day." c) "Be sure to eat high fiber foods when you get home to help you move your bowels." d) "Call your physician if there is even slight bleeding with your first bowel movement."
"You might feel some cramping and gas but these usually go away in about a day." Correct Explanation: After a colonoscopy, a client may experience mild cramping and flatulence which usually resolve within n 24 hours. If the client has a small growth or polyp removed, there may be a slight amount of bleeding that resolves on its own. The client should notify his physician if he experiences nausea, vomiting, fever, or excessive bleeding. The client also should avoid high-fat and high-fiber foods for at least 24 hours after the procedure. 1210
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? a) Cecum b) Jejunum c) Ileum d) Duodenum
Duodenum Correct 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. The duodenum is the site where bile and pancreatic enzymes enter the GI system. 1199
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? a) Ileum b) Cecum c) Duodenum d) Sigmoid colon
Sigmoid colon Correct 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. 1197
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? a) Ileum b) Liver c) Stomach d) Large intestine
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.1197
The nurse is assisting the physician in a percutaneous liver biopsy. In which position would the nurse assist the client to assume? a) Dorsal recumbent position b) A high Fowler's position c) Supine position d) Lithotomy 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.1343
When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the physician? a) "I really don't like to be in small, enclosed spaces." b) "I left all my jewelry and my watch at home." c) "I brought earphones to shut out the loud noise." d) "I haven't had anything to eat or drink since midnight last night."
"I really don't like to be in small, enclosed spaces." Correct Explanation: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful. 1207
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? a) Green b) Red c) Black d) Dark brown
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. 1201
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure? a) Client's tolerance for pain and discomfort b) Client's ability to retain the barium c) Gag reflex d) Signs of perforation
Client's tolerance for pain and discomfort Explanation: The nurse has to assess the client's tolerance for pain and discomfort during the procedure. The nurse should assess the signs of perforation and the gag reflex after the procedure of EGD and not during the procedure. Assessing the client's level for retaining barium is important for a diagnostic test that involves the use of barium. EGD does not involve the use of barium.1208
The nurse is assessing a 50-year-old, dark-skinned African American man and has noted that he appears jaundice. Most likely, the nurse made this observation by assessing which part of his body? a) Top of the hands and feet b) Mucous membranes c) Skin d) Nail beds
Mucous membranes Explanation: In very dark-skinned clients, inspect the hard palate, gums, conjunctiva, and surrounding tissues for discoloration.1344
The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position? a) Knee-chest b) Left Sim's lateral c) Supine with knees flexed d) Lithotomy
Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with his 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.1202
