Exam 3: GI Procedures (NCLEX)

The client has had a liver biopsy. which postprocedure intervention should the nurse implement? 1. instruct the client to void immediatly 2. keep the client NPO for 8 hours 3. place the client on the right side 4. monitor BUN and creatinine level

3

The client is being admitted to the outpatient department prior to an endoscopicretrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Whichpre-procedure instruction should the nurse teach? 1. Prepare to be admitted to the hospital after the procedure for observation. 2. If something happens during the procedure, then emergency surgery will be done. 3. Do not eat or drink anything after midnight the night before the test. 4. If done correctly, this procedure will correct the blockage of the stomach.

3

the client dx with end stage renal failure and ascites is scheduled for a paracentesis. which client teaching should the nurse discuss with the client? 1. explain the procedure will be done in the operating room 2. instruct the client a foley cath will have to be inserted 3. tell the client v/s will be taken frequently after the procedure 4. provide instructions on holding the breath when the hcp inserts the cath

3 hot water increases pruritus and soap will cause dry skin, which increases pruritus, therefore, the nurse should discuss this with the UAP

A nurse is providing wound care to a client 1 day after the client underwent an appendectomy. A drain was inserted into the incisional site during surgery. Which action should the nurse perform when providing wound care? 1. Remove the dressing and leave the incision open to air. 2. Remove the drain if wound drainage is minimal. 3. Gently irrigate the drain to remove exudate. 4. Clean the area around the drain moving away from the drain.

4 The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

two days after her cholecystectomy, a client has been experiencing nausea and vomiting. the client has a t tube in place. for what electrolyte imbalance will the nurse monitor? 1. hypernatremia 2. hyperkalemia 3. hypervolemia 4. hypokalemia

4 gastric secretions are high in postassium

A client has an appendectomy and develops peritonitis. The nurse should asses the client for an elevated temperature and which additional clinical indication commonly associated with peritonitis? 1. hyperactivity 2. extreme hunger 3. urinary retention 4. local muscular rigidity

4

a nurse is doing preop teaching for a client who will have a cholecystectomy. the nurse teaches that special care must be taken to prevent what postop complication? 1. hypostatic pneumonia 2. thrombosis 3. hemorrhage 4. paralytic ileus

1 the incision is located below the ribcage; therefore the coughing and deep breathing necessary to prevent pneumonia are especially difficult post op

after a liver biopsy the nurse should place the client in which position? 1. right side 2. left side 3. high fowlers 4. trendelenburg

1 when the client is placed on the right side, the biopsy site of the liver capsule is compressed against the chest wall, and the escape of blood or bile is impeded

The client diagnosed with appendicitis has undergone an appendectomy. At two hours postoperative, the nurse takes the vital signs and notes T 102.6 F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority. 1. Increase the IV rate. 2. Notify the health care provider. 3. Elevate the foot of the bed. 4. Check the abdominal dressing. 5. Determine if the IV antibiotics have been administered.

1, 3, 4, 5, 2 1. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained.3. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased BP. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia.4. The dressing should be assessed to determine if bleeding is occurring.5. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the HCP.2. The HCP should be notified when the nurse has the needed information.

A nurse is caring for a child who had a laproscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply. 1) Intake and Output 2) Measurement of Pain 3) Tolerance to low-residue diet 4) Frequency of dressing changes 5) Auscultation of bowel sounds

125

a 32 y/o client had a cholecystectomy 2 hrs ago. the client weighs 250 lbs and had general anesthesia. the client is c/o pain. priority nursing dx at this time: 1. alteration in comfort 2. high risk for airway impairment 3. alteration in fluid volume 4. knowledge deficit

2

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: 1. Provide access for wound irrigation. 2. Promote drainage of wound exudates. 3. Minimize development of scar tissue. 4. Decrease postoperative discomfort.

2 Drains are inserted postoperatively in appendectomies when an abscess was present or the appendix was perforated. The purpose is to promote drainage of exudate from the wound and facilitate healing. A drain is not used for irrigation of the wound. The drain will not minimize scar tissue development or decrease postoperative discomfort.

Postoperative nursing care for a client after an appendectomy should include which of the following? 1. Administering sitz baths four times a day. 2. Noting the first bowel movement after surgery. 3. Limiting the client's activity to bathroom privileges. 4. Measuring abdominal girth every 2 hours.

2 Noting the client's first bowel movement after surgery is important because this indicates that normal peristalsis has returned. Sitz baths are used after rectal surgery, not appendectomy. Ambulation is started the day of surgery and is not confined to bathroom privileges. The abdomen should be auscultated for bowel sounds and palpated for softness, but there is no need to measure the girth every 2 hours.

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

B

Your patient is post-op day 3 from a cholecystectomy due to cholecystitis and has a T-Tube. Which finding during your assessment of the T-Tube requires immediate nursing intervention? A. The drainage from the T-Tube is yellowish/green in color. B. There is approximately 750 cc of drainage within the past 24 hours. C. The drainage bag and tubing is at the patient's waist. D. The patient is in the Semi-Fowler's position.

B

A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."

B Shoulder pain occurs due to free air that is introduced into the abdomen during laparoscopic surgery.

A nurse is providing discharge teaching to a client who is postoperative following open cholecystectomywith T-tube placement. Which of the following instructions should the nurse include in the teaching?(Select all that apply. A. Take baths rather than showers. B. Clamp T-tube for 1 to 2 hr before and after meals. C. Keep the drainage system above the level of the abdomen. D. Expect to have the T-tube removed 3 days postoperatively.

BC

the nurse is caring for a pt who had an open cholecystectomy 24 hrs ago. which of the follwing actions should the nurse take to assist the pt to maintain an effective breathing pattern? select all that apply a. place in a supine position b. provide analgesics for pain c. encourage coughing and deep breathing d. monitor bowel sounds e. assist with splinting during coughing f. maintain bedrest for 48 hrs after

BCE pain relief allows comfortable breathing, preventing shallow respiration's and guarding, splinting makes coughing more comfortable, encouraging coughing and deep breathing to keep lung clear

After assisting with a needle biopsy of the liver at a patient's bedside, the nurse should a. put pressure on the biopsy site using a sandbag. b. elevate the head of the bed to facilitate breathing. c. place the patient on the right side with the bed flat. d. check the patient's postbiopsy coagulation studies.

C

The nurse evaluates the effectiveness of a paracentesis in a patient who has ascites. Which measurement is most important for the nurse to note? a. Cardiac output b. Blood pressure c. Abdominal girth d. Intake and output

C

The physician orders a patient's T-Tube to be clamped 1 hour before and 1 hour after meals. You clamp the T-Tube as prescribed. While the tube is clamped which finding requires you to notify the physician? A. The T-Tube is not draining. B. The T-Tube tubing is below the patient's waist. C. The patient reports nausea and abdominal pain. D. The patient's stool is brown and formed.

C

You're precepting a nursing student who is helping you provide T-Tube drain care. You explain to the nursing student that the t-shaped part of the drain is located in what part of the biliary tract? A. Cystic duct B. Common hepatic duct C. Common bile duct D. Pancreatic duct

C

Your patient is unable to have a cholecystectomy for the treatment of cholecystitis. Therefore, a cholecystostomy tube is placed to help treat the condition. Which statement about a cholecystostomy (C-Tube) is TRUE? A. The C-Tube is placed in the cystic duct of the gallbladder and helps drain infected bile from the gallbladder. B. Gallstones regularly drain out of the C-Tube, therefore, the nurse should flush the tube regularly to ensure patency. C. The C-Tube is placed through the abdominal wall and directly into the gallbladder where it will drain infected bile from the gallbladder. D. The tubing and drainage bag of the C-Tube should always be level with the insertion site to ensure the tube is draining properly.

C

A 54-year-old man has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.6° F. d. The apical pulse is 104 beats/minute.

C A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct

C An aPTT of 54 seconds is above normal and indicates insufficient clotting ability. If the patient had surgery, significant bleeding complications postoperatively are very likely. Fluids can be given to eliminate the dehydration; the abscess can be assessed, and the obstructions in the cystic and common bile duct would be relieved with the cholecystectomy.

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1° F (38.9° C) d. Scant nasogastric (NG) tube drainage

C An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

A client has an appendectomy. This is an example of what kind of surgery? a. Diagnostic b. palliative c. ablative d. constructive

C Appendectomy is an example of ablative surgery. Diagnostic confirms or establishes a diagnosis, palliative relieves or reduces pain, and constructive restores function or appearance.

Twenty-four hours after endoscopic retrograde cholangiopancreatography (ERCP), a client develops left upper quadrant abdominal pain and has a temperature of 101° F (38.3° C). What is the nurse's best action? A. Administer acetaminophen for control of fever and pain. B. Document the finding, because it is a normal postprocedure event. C. Notify the health care provider. D. Increase the IV fluid rate.

C The client who has undergone an ERCP may develop complications such as perforation or sepsis manifested by fever and abdominal pain. The nurse should report these symptoms to the health care provider immediately.

To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure

To prepare a 56-year-old male patient with ascites for paracentesis, the nurse a. places the patient on NPO status. b. assists the patient to lie flat in bed. c. asks the patient to empty the bladder. d. positions the patient on the right side.q

C The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler's position and would not be able to lie flat without compromising breathing. Because no sedation is required for paracentesis, the patient does not need to be NPO.

After a colonoscopy, a client reports that he is experiencing abdominal fullness and cramping. What is the nurse's best action? A. Insert a rectal tube to assist in passing of flatus. B. Notify the physician immediately because a bowel perforation is suspected. C. Have the client consume only liquids for 4 to 6 hours after the test. D. Explain to the client that this feeling can be expected for several hours after the test.

D Feelings of abdominal fullness, cramping, and the passing of flatus are normally expected after a colonoscopy.

A 42-year-old woman is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast.

D Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.

The nurse receives the following information about a 51-year-old woman who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient has a permanent pacemaker to prevent bradycardia. b. The patient is worried about discomfort during the examination. c. The patient has had an allergic reaction to shellfish and iodine in the past. d. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

D If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort

Bobby, a 13 year old is being seen in the emergency room for possible appendicitis. An important nursing action to perform when preparing Bobby for an appendectomy is to:" a) administer saline enemas to cleanse the bowels b) apply heat to reduce pain c) measure abdominal girth d) continuously monitor pain

D Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation. Administering an enema or applying heat may cause perforation and abdominal girth may not change with appendicitis.

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

D Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation.

When preparing a patient for a capsule endoscopy study, what should the nurse do? A) Ensure the patient understands the required bowel preparation. B) Have the patient return to the procedure room for removal of the capsule. C) Teach the patient to maintain a clear liquid diet throughout the procedure. D) Explain to the patient that conscious sedation will be used during placement of the capsule.

A A capsule endoscopy study involves the patient performing a bowel prep to cleanse the bowel before swallowing the capsule. The patient will be on a clear liquid diet for 1 to 2 days before the procedure and will remain NPO for 4 to 6 hours after swallowing the capsule. The capsule is disposable and will pass naturally with the bowel movement, although the monitoring device will need to be removed.

The nurse is preparing a client for a CT (computed tomography) scanning of the abdomen with contrast. What question should be asked before the examination? A. "Are you allergic to iodine or seafood?" B. "Have you had anything to eat or drink within the past 12 hours?" C. "Have you finished drinking all the required fluid?" D. "Can you tolerate being tilted from side to side during the procedure?"

A Allergies to iodine or seafood can mean a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies are scheduled for CT without contrast to avoid anaphylactic reactions.

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals.

A Although the usual diet can be resumed, a low-fat diet is usually better tolerated for several weeks following surgery. Normal activities can be gradually resumed as the patient tolerates. Bile-colored drainage or pus, redness, swelling, severe pain, and fever may all indicate infection. The bandage may be removed the day after surgery, and the patient can shower.

Which patient statement indicates that the nurse's teaching following a gastroduodenostomy has been effective? a. "Vitamin supplements may prevent anemia." b. "Persistent heartburn is common after surgery." c. "I will try to drink more liquids with my meals." d. "I will need to choose high carbohydrate foods."

A Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

The nurse will anticipate preparing a 71-year-old female patient who is vomiting "coffee-ground" emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis.

A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

A 58-year-old woman has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a drink of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient's mouth with cold water

A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate.

The hospital administrator had undergone percutaneous transhepatic cholangiography. which assessment finding indicates complication after the operation? A. Fever and chills B. Hypertension C. Bradycardia D. Nausea and diarrhea

A Septicemia is a common complication after a percutaneous transhepatic cholangiography. Evidence of fever and chills, possibly indicative of septicemia, is important. Hypotension, not hypertension, is associated with septicemia. Tachycardia, not bradycardia, is most likely to occur. Nausea and diarrhea may occur but are not classic signs of sepsis

What is the nurse's best action for the client who has undergone a laparoscopic cholecystectomy and complains of "free air pain." A. Ambulate the client. B. Instruct the client to breathe deeply and cough. C. Maintain the client on bedrest with his or her legs elevated. D. Insert a rectal tube to facilitate the passage of flatus.

A The client who has undergone a laparoscopic cholecystectomy may complain of free air pain because of the retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide.

A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which actions from the agency policy for ERCP should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure.

A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO

The nurse is caring for a patient following an appendectomy. The patienttakes a deep breath, coughs, and then winces in pain. Which of thefollowing statements, if made by the nurse to the patient, is BEST?" A.) "Take three deep breaths, hold your incision, and then cough." B.) "That was good. Do that again and soon it won't hurt as much." C.) "It won't hurt as much if you hold your incision when you cough." D.) "Take another deep breath, hold it, and then cough deeply.

A most effective way of deep breathing and coughing, dilates airway and expands lung surface area