Chapter 52 - Assessment of the GI System
A client is scheduled for a colonoscopy. What does the nurse tell the client to do before the procedure is performed? a. "Begin a clear liquid diet at least 24 hours before the test." b. "Do not eat or drink anything for 12 hours before the test." c. "Give yourself tap water enemas until the fluid returns are clear." d. "Be sure to take all currently prescribed medications prior to the procedure."
A
The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client? a. Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) b. Auscultating bowel sounds in all abdominal quadrants c. Counting the number of bowel sounds in each abdominal quadrant over one minute. d. Observing the abdomen for symmetry and distention
A
What is a common gastrointestinal problem that older adults experience more frequently as they age? a. Decreased hydrochloric acid levels b. Excess lipase production c. Increased liver size d. Increased peristalsis
A
Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit? a. A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis b. A 36-year-old who needs teaching about an endoscopic retrograde cholangiopancreatography c. A 40-year-old who will need administration of IV midazolam hydrochloride (Versed) during an upper endoscopy d. A 46-year-old who was recently admitted with abdominal cramping and diarrhea of unknown causes
A
While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first? a. A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) b. A 54-year-old who is ready for discharge following a colonoscopy c. A 58-year-old who has just arrived for basal gastric secretion and gastric acid stimulation testing d. A 60-year-old with questions about an endoscopic ultrasound examination
A
A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider? a. Gas and flatulence b. Excessive bleeding c. Nausea and vomiting d. Severe rectal pain
B
A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client? a. Assesses the abdomen in the following sequence: inspection, palpation, percussion, auscultation b. Examines the RUQ of the abdomen last following all other assessment techniques. c. Have the client lie in a supine position with legs straight and arms at the sides d. Gently palpates any bulging mass and documents findings.
B
The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct? a. Auscultate the abdomen to determine the presence of bowel sounds. b. Notify the provider about this finding immediately. c. Palpate the client's abdomen to determine the outlines of the mass. d. Question the client about recent stool habits.
B
The nurse is educating a group of older adults about screening for colorectal cancer. Which statement by a group member indicates the need for further clarification about these guidelines? a. "A barium enema every 5 years is a screening option." b. "I will need to have a routine colonoscopy every 5 years." c. "My routine flexible sigmoidoscopy every 5 years is OK." d. "The 'virtual' colonoscopy every 5 years is acceptable."
B
The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique? a. Auscultation, percussion, palpation, inspection b. Inspection, auscultation, percussion, palpation c. Palpation, percussion, inspection, auscultation d. Percussion, auscultation, palpation, inspection
B
Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic? a. A 38-year-old who needs discharge instructions after having an endoscopic retrograde cholangiopancreatography (ERCP) b. A 40-year-old who needs laxatives administered and effectiveness monitored before a colonoscopy c. A 43-year-old recently admitted with nausea, abdominal pain, and abdominal distention d. A 50-year-old with epigastric pain who needs conscious sedation during a scheduled endoscopy procedure
B
Which factors place a client at risk for gastrointestinal (GI) problems? (Select All That Apply) a. Eating a high-fiber diet b. Smoking a half-pack of cigarettes per day c. Socioeconomic status d. Some herbal preparations e. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
B, C, D, E
The nurse is assessing a client who has come to the emergency department with acute abdominal pain. The client is very thin and the nurse observes visible peristaltic movements when inspecting the abdomen. What does the nurse suspect? a. Acute diarrhea b. Aortic aneurysm c. Intestinal obstruction d. Pancreatitis
C
The outpatient clinic nurse is caring for a recovering client who had a colonoscopy. The client asks for a drink. How does the nurse respond to this request? a. "After I hear bowel sounds, you can have a drink." b. "Twenty minutes after the procedure was completed, you may have some liquids." c. "When you are able to pass flatus (gas), you can have a drink." d. "You can have fluids when you get home and are settled."
C
Which substance, produced in the stomach, facilitates the absorption of vitamin B12? a. Glucagon b. Hydrochloric acid c. Intrinsic factor d. Pepsinogen
C
A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))? a. LLQ, RLQ, LUQ, RUQ b. LUQ, LLQ, RUQ, RLQ c. RLQ, LLQ, RUQ, LUQ d. RUQ, LUQ, RLQ, LLQ
D
After a colonoscopy, a client reports severe abdominal pain. The nurse obtains these data: temperature 100.2°F (37.9°C), pulse 122 beats/min, blood pressure 100/45 mm Hg, respirations 44 breaths/min, and O2 saturation 89%. Which request from the health care provider does the nurse implement first? a. Give cefazolin (Ancef) 500 mg IV. b. Infuse normal saline at 200 mL/hr. c. Give morphine sulfate 2 mg IV. d. Provide oxygen at 6 L/min per nasal cannula.
D
