EXAM 1 43-47

Hemorrhoids

A clinic patient has described recent dark-colored stools;the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the patients current health status would contraindicate FOBT?

Inability to take in adequate oral food or fluids within 7 days

A critical care nurse is caring for a patient diagnosed with acute pancreatitis. The nurse knows that the indications for starting parenteral nutrition (PN) for this patient are what?

Abdominal ultrasound poses no known safety risks of any kind.

A female patient has presented to the emergency department with right upper quadrant pain; the physician has ordered abdominal ultrasound to rule out cholecystitis (gallbladder infection). The patient expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?

Indicates acceptance of altered appearance and demonstrates positive self-image

A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection?

The patient may have cancer, but other GI disease must be ruled out.

A medical patients CA 19-9 levels have become available and they are significantly elevated. How should the nurse best interpret this diagnostic finding?

Report this finding to the patients primary care provider.

A nurse has obtained an order to remove a patients NG tube and has prepared the patient accordingly. After flushing the tube and removing the nasal tape, the nurse attempts removal but is met with resistance. Because the nurse is unable to overcome this resistance, what is the most appropriate action?

Medulla oblongata

A nurse in a stroke rehabilitation facility recognizes that the brain regulates swallowing. Damage to what area of the brain will most affect the patients ability to swallow?

Use warm saline to rinse the mouth as needed.

A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions?

Early diagnosis and treatment of gastroesophageal reflux disease

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer?

Premature removal of the G tube

A nurse is admitting a patient to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy?

Assess for a patent airway.

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

GI diseases often produce skin changes.

A nurse is assessing the abdomen of a patient just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the patients abdomen. How should the nurse best interpret this assessment finding?

Change the dressing no more than weekly.

A nurse is aware of the high incidence of catheter-related bloodstream infections in patients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections?

Upper GI tract

A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patients stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

-Lipase -Amylase -Trypsin

A nurse is caring for a patient admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply.

To remove gas from the stomach, To remove toxins from the stomach, To diagnose GI motility disorders

A nurse is caring for a patient who has a gastrointestinal tube in place. Which of the following are indications for gastrointestinal intubation? Select all that apply.

Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

A nurse is caring for a patient who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the patient?

Promptly report these indications of venous congestion.

A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action?

Inadequate nutrition and decreased saliva production can cause cavities

A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries?

Ineffective Role Performance Related to Parenteral Nutrition

A nurse is caring for a patient who is receiving parenteral nutrition. When writing this patients plan of care, which of the following nursing diagnoses should be included?

Inflammatory bowel disease

A nurse is caring for a patient who is scheduled for a colonoscopy and whose bowel preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?

Report possible signs of aspiration pneumonia to the primary care provider.

A nurse is caring for a patient with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The patients oxygen saturation is 89% by pulse oximetry. After ensuring the patients immediate safety, what is the nurses most appropriate action?

Risk for Infection Related to the Presence of a Subclavian Catheter

A nurse is caring for a patient with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this patient, what nursing diagnosis should the nurse prioritize?

Below the right nipple

A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain?

Apply local anesthetic to the back of the patients throat.

A nurse is caring for a patient with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy (UGF). How should the nurse in the radiology department prepare this patient?

Stomach emptying takes place more slowly.

A nurse is caring for an 83-year-old patient who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the patients health complaint?

-Clotted or displaced catheter - Pneumothorax -Hyperglycemia -Line sepsis

A nurse is creating a care plan for a patient who is receiving parenteral nutrition. The patients care plan should include nursing actions relevant to what potential complications? Select all that apply.

Use a combination of at least two accepted methods for confirming placement.

A nurse is creating a care plan for a patient with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?

Initiating the infusion slowly and monitoring the patients fluid and glucose tolerance

A nurse is initiating parenteral nutrition (PN) to a postoperative patient who has developed complications. The nurse should initiate therapy by performing which of the following actions?

TNA is less costly than PN

A nurse is participating in a patients care conference and the team is deciding between parenteral nutrition (PN) and a total nutritional admixture (TNA). What advantages are associated with providing TNA rather than PN?

Decreased mucus secretion

A nurse is performing an abdominal assessment of an older adult patient. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.

A nurse is preparing to administer a patients intravenous fat emulsion simultaneously with parenteral nutrition (PN). Which of the following principles should guide the nurses action?

Contact the pharmacy to obtain a new bag of PN.

A nurse is preparing to administer a patients scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that the presence of small amounts of white precipitate are present in the bag. What is the nurses best action?

-Preparing the patient to troubleshoot for problems, -Teaching the patient and family strict aseptic technique, -Teaching the patient and family how to set up the infusion

A nurse is preparing to discharge a patient home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply.

Place distal tip to nose, then ear tip and end of xiphoid process.

A nurse is preparing to place a patients ordered nasogastric tube. How should the nurse best determine the correct length of the nasogastric tube?

Pepsin

A nurse is promoting increased protein intake to enhance a patients wound healing. The nurse knows that enzymes are essential in the digestion of nutrients such as protein. What is the enzyme that initiates the digestion of protein?

Frequent lung auscultation

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding?

Avoid carbonated drinks.

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?

Brushing the patients teeth with a toothbrush and small amount of toothpaste

A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation?

Youll need to have enemas the day before the test.

A nurse is providing preprocedure education for a patient who will undergo a lower GI tract study the following week. What should the nurse teach the patient about bowel preparation?

Risk for Impaired Skin Integrity Related to the Presence of NG Tube

A nurse is writing a care plan for a patient with a nasogastric tube in place for gastric decompression. What risk nursing diagnosis is the most appropriate component of the care plan?

A 65-year-old man with alcoholism who smokes

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer?

Prevent aspiration

A nursing educator is reviewing the care of patients with feeding tubes and endotracheal tubes (ET). The educator has emphasized the need to check for tube placement in the stomach as well as residual volume. What is the main purpose of this nursing action?

Hypoactive

A nursing student has auscultated a patients abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patients bowel sounds?

Hemorrhoids

A patient asks the nursing assistant for a bedpan. When the patient is finished, the nursing assistant notifies the nurse that the patient has bright red streaking of blood in the stool. What is this most likely a result of?

Measure and record drainage.

A patient has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurses priority during this aspect of the patients care?

Orogastric tube

A patient has been brought to the emergency department by EMS after telling a family member that he deliberately took an overdose of NSAIDs a few minutes earlier. If lavage is ordered, the nurse should prepare to assist with the insertion of what type of tube?

Your appendix doesnt play a major role, so you wont notice any difference after you recovery from surgery.

A patient has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The patient is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

Risk for Aspiration Related to Inhalation of Gastric Contents

A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care?

Regurgitation of undigested food

A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom?

-Changes in lifestyle -Loss of eating as a social behavior -Sleep disturbances related to frequent urination during nighttime infusions

A patient has been discharged home on parenteral nutrition (PN). Much of the nurses discharge education focused on coping. What must a patient on PN likely learn to cope with? Select all that apply.

Decreased motility

A patient has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the patients gastrointestinal function? Select all that apply.

Risk For Impaired Skin Integrity Related to Peptic Ulcers

A patient has been scheduled for a urea breath test in one months time. What nursing diagnosis most likely prompted this diagnostic test?

A quantitative fecal immunochemical test

A patient has come to the clinic complaining of blood in his stool. A FOBT test is performed but is negative. Based on the patients history, the physician suggests a colonoscopy, but the patient refuses, citing a strong aversion to the invasive nature of the test. What other test might the physician order to check for blood in the stool?

Colonoscopy

A patient has come to the outpatient radiology department for diagnostic testing. Which of the following diagnostic procedures will allow the care team to evaluate and remove polyps?

NSAIDs

A patient has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should instruct the patient to avoid which of the following prior to collecting a stool sample?

Persistently low hemoglobin and hematocrit

A patient is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production?

Keep the vent lumen above the patients waist.

A patient is concerned about leakage of gastric contents out of the gastric sump tube the nurse has just inserted. What would the nurse do to prevent reflux gastric contents from coming through the blue vent of a gastric sump tube?

Wash the area around the tube with soap and water daily.

A patient is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?

Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food.

A patient presents at the walk-in clinic complaining of recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the patient may have an ulcer. How would the nurse explain the formation and role of acid in the stomach to the patient?

Dilute the concentration of the feeding solution.

A patient receiving tube feedings is experiencing diarrhea. The nurse and the physician suspect that the patient is experiencing dumping syndrome. What intervention is most appropriate?

An effective means of communicating with the nurse

A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time?

Increase fluid intake to evacuate the barium.

A patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery?

Promoting maximum shoulder function

A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include?

Regurgitation and aspiration are less likely.

A patient who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The patient has since become comatose and the patients family asks the nurse why the physician is recommending the removal of the patients NG tube and the insertion of a gastrostomy tube. What is the nurses best response?

The patients BUN and creatinine levels are within reference range following the CT.

A patient will be undergoing abdominal computed tomography (CT) with contrast. The nurse has administered IV sodium bicarbonate and oral acetylcysteine (Mucomyst) before the study as ordered. What would indicate that these medications have had the desired therapeutic effect?

The test is noninvasive.

A patient with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the patient, what advantage should the nurse describe?

Digestion of proteins

A patient with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The patients intake of trypsin facilitates what aspect of GI function?

An internal retention disc secures the tube against the stomach wall.

A patient with dysphagia is scheduled for PEG tube insertion and asks the nurse how the tube will stay in place. What is the nurses best response?

The patient will require an upper endoscopy every 6 months to detect malignant changes.

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care?

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

A patients NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next?

Entry of large amounts of water into the small intestine because of osmotic pressure

A patients enteral feedings have been determined to be too concentrated based on the patients development of dumping syndrome. What physiologic phenomenon caused this patients complication of enteral feeding?

Chemical phlebitis

A patients health decline necessitates the use of total parenteral nutrition. The patient has questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV. The nurse should know that peripheral administration of high-concentration PN formulas is contraindicated because of the risk for what complication?

Confirm placement of the tube prior to each medication administration.

A patients new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patients care plan accordingly. What intervention should the nurse include in the patients plan of care?

Nontunneled central catheter

A patients physician has determined that for the next 3 to 4 weeks the patient will require parenteral nutrition (PN). The nurse should anticipate the placement of what type of venous access device?

The patient can resume a normal routine immediately.

A patients sigmoidoscopy has been successfully completed and the patient is preparing to return home. Which of the following teaching points should the nurse include in the patients discharge education?

Lower esophageal sphincter

A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD?

Fluids must be increased to facilitate the evacuation of the stool.

An adult patient is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the patient has completed the test?

Percussion

An advanced practice nurse is assessing the size and density of a patients abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?

Palpate the patients parotid glands to detect swelling and tenderness.

An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?

Glucagon

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body?

Streaks of blood present in the stool

An inpatient has returned to the medical unit after a barium enema. When assessing the patients subsequent bowel patterns and stools, what finding should the nurse report to the physician?

Determining the patients ability to understand and cooperate with the procedure

Prior to a patients scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment?

Avoid vitamin C for 72 hours before you start the test.

Probably the most widely used in-office or at-home occult blood test is the Hemoccult II. The patient has come to the clinic because he thinks there is blood in his stool. When you reviewed his medications, you noted he is on antihypertensive drugs and NSAIDs for early arthritic pain. You are sending the patient home with the supplies necessary to perform 2 hemoccult tests on his stool and mail the samples back to the clinic. What instruction would you give this patient?

Prepare to meet the patients psychosocial needs.

Results of a patients preliminary assessment prompted an examination of the patients carcinoembryonic antigen (CEA) levels, which have come back positive. What is the nurses most appropriate response to this finding?

I flush my tube with water before and after each of my medications.

The management of the patients gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

-Splenic vein -Inferior mesenteric vein -Gastric vein

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply.

Checking the patients capillary blood glucose levels regularly

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurses assessments most directly addresses a major complication of TPN?

Leave the tube in its present position.

The nurse is assessing placement of a nasogastric tube that the patient has had in place for 2 days. The tube is draining green aspirate. What is the nurses most appropriate action?

Inform the primary care provider of this finding.

The nurse is caring for a patient who has a diagnosis of AIDS. Inspection of the patients mouth reveals the new presence of white lesions on the patients oral mucosa. What is the nurses most appropriate response?

Gently rotate the tube.

The nurse is caring for a patient who is postoperative from having a gastrostomy tube placed. What should the nurse do on a daily basis to prevent skin breakdown?

-Secretion of mucus -Absorption of nutrients -Movement of nutrients into the bloodstream

The nurse is caring for a patient with a duodenal ulcer and is relating the patients symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply.

The patient is agitated.

The nurse is preparing to insert a patients ordered NG tube. What factor should the nurse recognize as a risk for incorrect placement?

Inspection, auscultation, percussion, and palpation

The nurse is preparing to perform a patients abdominal assessment. What examination sequence should the nurse follow?

Lying on the left side with legs drawn toward the chest

The nurse is providing health education to a patient scheduled for a colonoscopy. The nurse should explain that she will be placed in what position during this diagnostic test?

Avoid applying suction on or near the suture line.

The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient?

Presence of a painless sore with raised edges

The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

The absorption into the bloodstream of nutrient molecules produced by digestion

The physiology instructor is discussing the GI system with the pre-nursing class. What should the instructor describe as a major function of the GI tract?

Organic fruit juice

The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay?

2 to 3 months

You are caring for a patient who was admitted to have a low-profile gastrostomy device (LPGD) placed. How soon after the original gastrostomy tube placement can an LPGD be placed?