CHAPTER 55: CARE OF PATIENTS WITH STOMACH DISORDERS

10. The nurse is caring for a client with peptic ulcer disease. Which assessment finding indicates to the nurse that the client most likely has an ulcer in the stomach rather than in the duodenum? a. Body mass index (BMI) is 16.6. b. Stool is positive for occult blood. c. Client has had four ulcers in the last 5 years. d. Hemoglobin is 13 g/dL and hematocrit is 42%.

ANS: A A BMI of 17.6 indicates that the client is underweight (<18.5 is underweight in adults). This finding is more commonly seen with gastric ulcers than with duodenal ulcers because the pain is made worse with food ingestion. Occult blood and low hemoglobin and hematocrit levels may be seen with both gastric and duodenal ulcers. Recurrence is more commonly seen with duodenal than with gastric ulcers.

22. The nurse is caring for a client who reports persistent epigastric pain, heartburn, and nausea, despite faithfully taking ranitidine (Zantac), aluminum hydroxide (Amphojel), and metronidazole (Flagyl) as prescribed. Which is the nurse's best response? a. "Is your pain better or worse after you eat?" b. "Have you tried elevating the head of your bed at night?" c. "Have you been taking the Amphojel and Flagyl together?" d. "Have you been experiencing foul-smelling diarrhea lately?"

ANS: D Peptic ulcer disease (PUD) symptoms that are not alleviated by medications may indicate Zollinger-Ellison syndrome, a similar condition that is often refractory to treatment. A hallmark of Zollinger-Ellison syndrome is diarrhea and steatorrhea, with frothy, foul-smelling diarrhea.

5. The home care nurse is caring for a client who has recently undergone a subtotal gastrectomy. The nurse notes that the client's tongue is shiny and beefy red. Which assessment question does the nurse ask the client regarding this finding? a. "Have you been taking your multivitamin every day?" b. "How much weight have you lost since your surgery?" c. "Have you been experiencing heartburn or nausea after eating?" d. "What kind of mouthwash do you use after you brush your teeth?"

ANS: A Symptoms of atrophic glossitis are caused by a decrease in vitamin B12, which results from lack of intrinsic factor secondary to surgical resection of a portion of the stomach. The nurse should check to see whether the client has been taking the prescribed multivitamin every day. The other questions will not help the nurse discover the cause of this finding.

19. The nurse is caring for a client who recently has undergone a partial gastrectomy. Two hours after eating lunch, the client becomes dizzy, diaphoretic, and confused. Which is the nurse's priority action? a. Check the client's blood sugar level. b. Increase the client's IV infusion rate. c. Auscultate the client's bowel sounds. d. Place the client in high Fowler's position.

ANS: A The client's symptoms are consistent with late dumping syndrome, in which hypoglycemia is caused by increased insulin levels. The client's blood sugar level should be checked immediately. The other actions are not necessary.

15. The nurse is caring for a client with suspected upper GI bleeding. The nurse inserts a nasogastric (NG) tube for gastric lavage and checks placement of the tube in the stomach. When fluid is aspirated from the tube, the pH is found to be 6. Which is the priority action of the nurse? a. Obtain an order for a stat chest x-ray. b. Auscultate over the lung fields bilaterally. c. Assess whether the tube is coiled in the client's throat. d. Auscultate over the epigastric area while instilling air.

ANS: A The pH of gastric contents should be below 3.5. A stat chest x-ray should be obtained whenever any doubt arises regarding NG tube placement. The other methods are not appropriate for confirming placement.

3. The nurse is caring for a client who will undergo a gastrectomy the following day. Which interventions are included in the postoperative plan of care for the client? (Select all that apply.) a. Monitor and record accurate intake and output (I&O). b. Remind the client to use the incentive spirometer twice daily. c. Change abdominal dressings daily using medical asepsis. d. Remind the client daily to use patient-controlled analgesia (PCA) before pain becomes severe. e. Keep the head of the client's bed elevated whenever possible. f. Irrigate the nasogastric tube with normal saline every 8 hours PRN.

ANS: A, D, E I&O should be recorded to monitor for fluid overload or deficit. Pain medication is most effective when taken before pain becomes severe. Keep the client's head of the bed elevated to prevent reflux. The spirometer should be used at least every hour to prevent atelectasis and pneumonia. Surgical asepsis (sterile technique) must be used for dressing changes and the site must be assessed each shift, necessitating a dressing change each shift.

12. The nurse is caring for a client who has just arrived in the emergency department reporting epigastric pain. The client says that emesis earlier in the day looked like coffee grounds. What does the nurse prepare to do for the client first? a. Check the client's stool for occult blood. b. Insert 18-gauge IV lines with normal saline infusions. c. Insert a nasogastric tube and prepare for gastric lavage. d. Determine whether the client has a history of ulcers.

ANS: B "Coffee ground" emesis is indicative of bleeding in which the blood has been partially digested by gastric acid. This client is at risk for hemorrhage and severe volume depletion and requires two large-bore IVs immediately. The client next will most likely need a saline lavage. Checking the stool and obtaining a history can be done later when the client is stable.

2. The nurse is caring for a client with a nasogastric (NG) tube after an episode of GI bleeding. Which interventions are included in the nursing care plan? (Select all that apply.) a. Monitor and record intake and output every 8 hours. b. Monitor hemoglobin and hematocrit laboratory values. c. Ensure that suction is set on high continuous for Levin tubes. d. Measure the client's girth and/or assess for distention daily. e. Pin the tube to the client's gown, so it cannot be dislodged. f. Check vital signs and orthostatic blood pressure every 4 hours and PRN.

ANS: B, E, F The client with an NG tube post-GI bleeding should have his or her hemoglobin and hematocrit monitored and the tube pinned to the client's gown so it cannot be dislodged; also, vital signs should be checked every 4 hours. Intake and output should be assessed and recorded every 4 hours or more often as needed. Suction should be set on low intermittent suction for Levin tubes. The client should be observed for distention when the nurse makes other assessments.

21. The nurse is caring for a client who will be discharged from the hospital following surgery for advanced gastric cancer. The client's daughter verbalizes the fear that she will not be able to manage her parent's symptoms adequately at home. Which is the nurse's best response? a. "The nurses have taught you everything you need to know to care for your parent." b. "Don't worry, the pain pills will keep your parent comfortable until the end." c. "I will ask the social worker to arrange for a hospice nurse to help you at home." d. "I will ask the health care provider to review the care instructions with you again."

ANS: C Hospice nurses can assist family members with caring for clients who are terminally ill. The nurse should not belittle the daughter's concerns, nor should she ask the provider to review the discharge instructions again. The hospice nurse can provide not only physical care, but support for the family as they care for a loved one at home.

26. The nurse is to insert a nasogastric (NG) tube for a client with upper GI bleeding. Which instruction does the nurse give to the client before starting the procedure? a. "You may take some sips of water when I begin to insert the tube into your nose." b. "Please hold your breath when I insert the tube through your nose." c. "Tilt your head down to your chest when the tube gets to the back of your throat." d. "The distance from the end of your nose to your navel tells me which size tube to use."

ANS: C Tilting the head down toward the chest after the NG tube has reached the back of the throat will facilitate intubation of the esophagus rather than the trachea. The client should be encouraged to mouth-breathe and swallow during the procedure. The tube should be measured from the nose to the earlobe to the xiphoid process. Sips of water should be encouraged once the tube is at the back of the throat, not at the beginning of the procedure.

6. The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? a. "I will avoid drinking coffee, even if it is decaffeinated." b. "I will take a multivitamin every morning with breakfast." c. "I will go to my tai chi class to wind down after a busy day." d. "I will take my medication every day until my heartburn is gone."

ANS: D Long-term medication compliance is crucial to eradicate Helicobacter pylori and prevent recurrence. The nurse stresses the importance of continuing medications for the entire time prescribed. Decaffeinated coffee is a better choice than caffeinated coffee for the client with peptic ulcer disease. Stress management should also be part of the treatment plan. Good nutrition is always important.

24. A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority? a. Keep the client on strict bedrest for 8 hours. b. Delegate taking vital signs to the nursing assistant. c. Increase the IV rate to flush the kidneys. d. Assess the client's gag reflex.

ANS: D The client will receive moderate sedation and a numbing agent during the procedure. The client may temporarily lose his or her gag reflex; this should be checked before the client is permitted to eat anything by mouth. The client does not require strict bedrest for 8 hours or increased fluid to flush the kidneys. The nurse can delegate the taking of vital signs to unlicensed assistive personnel (UAP) such as the nursing assistant, but this is not the priority.

18. The nurse is caring for a client who has recently undergone a partial gastrectomy. The client reports becoming dizzy and sweaty with heart palpitations about 2 hours after eating. The client is now afraid to eat anything. Which is the nurse's best response? a. "Drink at least 6 ounces of fluid before each meal." b. "Try a clear liquid diet for the next few days." c. "You probably should avoid dairy products." d. "Limit carbohydrate intake with meals."

ANS: D The client's symptoms are consistent with late dumping syndrome, which is caused by a rapid rise in insulin secretion in response to increased glucose levels after eating. Eliminating sugary foods and eating low to moderate carbohydrates with meals helps manage this problem. Liquids should be taken between meals. Clear liquids and limited dairy products are not needed.

11. The nurse is caring for a client who has been brought to the emergency department with upper GI bleeding. The client is vomiting copious amounts of bright red blood. Which is the nurse's priority action? a. Ensure that the client has a patent airway. b. Start a normal saline IV infusion. c. Gather equipment to start a saline lavage. d. Assess the client for causative factors.

ANS: A Airway always comes first. The client must have a patent airway. The client does need an IV and a saline lavage via nasogastric (NG) tube, but these actions are not as important as maintaining the airway. Assessing for causative factors will be important after the client has stabilized.

25. The nurse is caring for a client who has received multiple serious injuries in a motor vehicle accident. The client asks the nurse why ranitidine (Zantac) is prescribed because she does not have any abdominal pain. Which is the nurse's best response? a. "It will help prevent the development of a stomach ulcer from the stress of your injuries." b. "It will help prevent aspiration pneumonia when you are anesthetized during surgery tomorrow." c. "It will help your throat heal after it was irritated from the nasogastric tube." d. "It will help prevent nausea and vomiting from the narcotic pain medications that you are taking."

ANS: A Clients who have sustained traumatic injuries are at risk for development of stress ulcers during recovery. H2-antagonist medications may be prescribed to prevent stress ulcers. Zantac will not prevent aspiration pneumonia, esophageal healing after nasogastric intubation, or nausea from narcotic pain medications.

8. An older client is admitted to the hospital with acute gastritis. The health care provider orders magnesium hydroxide (Mylanta) 1 hour and 3 hours after meals and at bedtime. Which action by the nurse is most appropriate? a. Check the client's renal function studies before giving the drug. b. Call the health care provider and ask for a different antacid for the client. c. Assess the client's pain and treat pain if present. d. Assist the client in ordering bland food from the menu.

ANS: A Hypermagnesemia can develop if the client's kidneys are not functioning well because Mylanta contains magnesium, which is excreted via the kidneys. Kidney function declines as a normal age-related change, so the nurse should be cautious to check kidney function before administering this medication. The client may be able to take the medication; without further information, the nurse should not yet call the provider. Assessing and treating pain and helping the client choose appropriate foods are good interventions, but they are not specific to ensuring safety regarding the medication ordered.

7. The nurse is teaching a health promotion class about preventing cancer. Which statement by a student indicates understanding of gastric cancer development? a. "I should skip my morning bacon and egg sandwich to reduce my risk of gastric cancer." b. "I have been lactose intolerant for many years, so I should have a yearly test for gastric cancer." c. "I should switch from regular to decaffeinated coffee to reduce my risk of gastric cancer." d. "I am at low risk for developing gastric cancer because I am a vegetarian and I eat only organic produce."

ANS: A Regular consumption of processed foods with nitrates (including bacon) can increase risk for gastric cancer. Lactose intolerance, coffee intake, and vegetarian diet are not factors in gastric cancer development.

9. The nurse is caring for a client with chronic gastritis. The client asks the nurse how to prevent another flare-up of gastritis. Which is the nurse's best response? a. "Join a support group to help you stop smoking." b. "Take a multivitamin with iron and folic acid every day." c. "Make sure to include plenty of fresh vegetables in your diet." d. "Make sure that your weight stays within normal limits."

ANS: A Smoking and stress contribute to the development of gastritis, so the client should join a support group to help him quit smoking. Multivitamins, fiber, and weight management do not help prevent gastritis development.

23. A client with Zollinger-Ellison syndrome will be admitted to the medical unit. Which intervention does the nurse include in the client's nursing plan of care? a. Performing a urine test for ketones every morning before breakfast b. Performing perineal care and applying a moisture barrier twice daily c. Assessing the abdomen for fluid wave and shifting dullness every 8 hours d. Keeping 2 units of packed red blood cells on hold at all times

ANS: B Clients with Zollinger-Ellison syndrome often experience severe diarrhea and steatorrhea, so the nurse should include careful perineal care in the plan of care. Abdominal fluid wave testing and shifting dullness checks for ascites, which is not seen with Zollinger-Ellison syndrome. Ketones are not associated with this condition either. Blood transfusions are not part of the typical management plan for clients with Zollinger-Ellison syndrome, and blood would not be kept on hand unless the client was bleeding.

13. The nurse is caring for a client who presents with chronic epigastric pain, heartburn, and anorexia. The client asks the nurse how the doctor can best determine whether the symptoms are caused by gastritis. Which is the nurse's best response? a. "You will be asked to drink a barium solution while x-rays are taken of your stomach." b. "The doctor will take a look inside your stomach using a tube with a light on the end of it." c. "A CT scan of your abdomen will show whether inflammation is present in your stomach." d. "A blood sample will be sent to the laboratory to determine whether you have a stomach infection or bleeding."

ANS: B Endoscopy (esophagogastroduodenoscopy) with biopsy is the best method for diagnosing gastritis. Computed tomography (CT) scans, upper GI series, and blood samples are less accurate for making the diagnosis of gastritis.

20. The nurse is caring for a client with advanced gastric cancer who is scheduled for palliative surgery to relieve gastric outlet obstruction. The client asks the nurse why he should bother having the surgery, because he will not be cured. Which is the nurse's best response? a. "It will allow the doctors to determine more accurately how long you have to live." b. "It will relieve the obstruction so you will be more comfortable and able to eat again." c. "It will remove much of the tumor so that chemotherapy will be more effective." d. "It will help prevent the tumor from spreading to other parts of your body."

ANS: B Palliative surgery will relieve the gastric outlet obstruction and allow the client to eat again, thus improving quality of life. The surgery will not provide physicians with an accurate prognosis, make chemotherapy more effective, or prevent metastasis.

2. The nurse is caring for a female client who has just received a prescription for misoprostol (Cytotec). Which instructions does the nurse provide to the client regarding this medication? a. "You may dissolve the contents of the capsule in warm water if it is difficult for you to swallow." b. "Take this medication on an empty stomach just before going to bed every evening." c. "You will need to stop taking your magnesium hydroxide (Mylanta) now that you are on this drug." d. "You should add extra fiber to your diet because this medication may cause constipation."

ANS: C Misoprostol is a prostaglandin analogue. Clients on this medication need to avoid magnesium-containing antacids; Mylanta contains magnesium. Clients should not dissolve the pill, should take misoprostol with food, and do not need to take precautions against constipation while on this drug.

4. The nurse is caring for a client with peptic ulcer disease. The client vomits a large amount of undigested food after breakfast. Which intervention does the nurse prepare to provide for the client? a. Administer a soap suds cleansing enema. b. Change the client's diet to clear liquids only. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Administer prochlorperazine (Compazine) 10 mg IM.

ANS: C Symptoms of abdominal distention and nausea and vomiting of undigested food signal pyloric obstruction. Treatment is aimed at decompression of the stomach by an NG tube and restoration of fluid and electrolyte balance. The client should remain NPO, and a soap suds cleansing enema is not indicated. Decompressing the stomach should alleviate the nausea, but if antiemetics are ordered, they would not take priority over decompressing the stomach.

1. The nurse is caring for a client who has recently undergone a partial gastrectomy. The client asks the nurse which foods would be best for him to have for breakfast. Which menu items does the nurse recommend for the client?(Select all that apply.) a. Blueberry pancakes with maple syrup b. A half-grapefruit with a blueberry muffin c. Plain bagel with margarine or butter d. Raisin bran with milk and artificial sweetener e. Scrambled eggs with cheese and a slice of bacon f. One half cup of cottage cheese with canned pears

ANS: C, E, F Clients who have undergone gastrectomy surgery are at risk for dumping syndrome after meals. To help avoid dumping syndrome, clients should avoid concentrated sweets and fluids at mealtimes. Clients should choose foods that are relatively high in protein and fat, with relatively low carbohydrate content. Good choices are the bagel with butter or margarine, the scrambled egg breakfast, and the cottage cheese with unsweetened canned fruit. The pancakes and syrup are too sweet and have too many carbohydrates. The muffin is high in refined carbohydrates, and fresh fruit should be eaten with caution. Raisin bran is too high in fiber, and beverages (milk) should be taken between meals.

1. The nurse is caring for a client who is at risk for developing gastritis. Which finding from the client's history leads the nurse to this conclusion? a. Client is lactose intolerant and cannot drink milk. b. Client recently traveled to Mexico and South America. c. Client works at least 60 hours per week in a stressful job. d. Client takes naproxen sodium (Naprosyn) 500 mg daily for arthritis pain.

ANS: D Motrin and other NSAIDs can cause gastritis, even if symptoms are not yet apparent. Stress, travel, and spicy foods do not increase the risk for gastritis.

17. The nurse is caring for a client with gastritis who will undergo a nuclear medicine GI bleeding study in the morning. What instruction for preparation does the nurse give the client? a. "You cannot eat anything after midnight." b. "You should drink several glasses of water in the morning." c. "You must make arrangements for transportation home." d. "No special preparations are required for this test."

ANS: D No special preparations are required for this test, so the client is not required to be NPO or to drink several glasses of water. Sedation is not used, so the client does not need to find transportation home.

16. A client has been taking an antacid for several weeks without improvement in symptoms. Which response by the nurse is most helpful? a. "Tell me exactly how you take your antacid." b. "Would you be willing to try a more expensive medication?" c. "Are you sure you are taking this exactly as ordered?" d. "Let's ask the health care provider if the dose can be doubled."

ANS: A Antacids can be effective anywhere from 30 minutes to 3 hours after eating. Their neutralizing effect is eliminated when they are taken on an empty stomach. However some people take them before eating to prevent symptoms. The nurse should first discover how the client takes the medication before suggesting other medications or increasing the dose. Asking the client whether the medication is being taken exactly as ordered is a closed-ended question, which is not a good communication tool. Also, the way the statement is phrased is likely to place the client on the defensive.

14. The nurse is caring for a client with a history of heart failure and chronic gastritis. The client tells the nurse about taking 2 teaspoons of sodium bicarbonate every night before going to bed to prevent heartburn. Which is the nurse's best response? a. "You should let the doctor know right away if you develop diarrhea." b. "I will let your doctor know so a safer antacid can be prescribed for you." c. "Do not take that with milk, because the combination can cause kidney stones." d. "Make sure that you mix the sodium bicarbonate with at least 8 ounces of water."

ANS: B Sodium bicarbonate can cause fluid retention and edema, which can be dangerous for clients with heart failure. The provider should be notified so that an alternative antacid can be prescribed. The other statements do not reflect an accurate concern with sodium bicarbonate.

3. The nurse is caring for a client with a gastric ulcer who suddenly develops sharp mid-epigastric pain. The nurse notes that the client's abdomen is hard and very tender to light palpation. Which is the priority action of the nurse? a. Place the client in a knee-chest position. b. Prepare the client for emergency surgery. c. Insert a nasogastric (NG) tube to low intermittent suction. d. Assess the client's pain and administer analgesics.

ANS: B Sudden, sharp mid-epigastric pain is indicative of perforation, which is a surgical emergency. Pain medication should not be administered just now because the surgeon will need to assess the client's abdomen, and the client will need to sign an operative permit. The client may assume the knee-chest position in an attempt to relieve pain. The provider may order placement of an NG tube, but this would not take priority over getting the client ready for surgery.