Gastrointestinal Disorders
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. The client's partner reports that the client has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's partner. The question by the nurse that demonstrates the nurse's understanding of Mallory-Weiss tearing is
"Has your partner had recent forceful vomiting?"
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation."
The nurse is evaluating the lifestyle modifications a client has made to prevent gastroesophageal reflux. Which statement indicates that the client understands how to prevent reflux?
"I try to eat smaller amounts of food more often throughout the day."
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
"I'll eat frequent, small, bland meals that are high in fiber."
The nurse is instructing a client who will have a barium enema in the morning. Which statements made by the client demonstrate that the instruction has been effective? Select all that apply.
-"For dinner, I will eat gelatin, water, and juice." -"I will need to take laxatives before and after the procedure."
The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease (GERD). What should the nurse instruct the client to do? Select all that apply.
-Avoid a diet high in fatty foods. -Avoid beverages that contain caffeine. -Avoid all alcoholic beverages.
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
Acute pain related to biliary spasms
A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?
Cullen's sign
The nurse is preparing a client with possible cholelithiasis for an oral cholecystography tomorrow. What should the nurse discuss with the client?
Ask the client if they are allergic to iodine or shellfish.
A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain described as "feeling full and uncomfortable." Which assessment should the nurse perform first?
Assess patency of the NG tube.
Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
Change the tube feeding administration set at least every 24 hours.
The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first?
Check the function of the suction equipment.
An adolescent girl with severe malnutrition is admitted to an acute care facility. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the care plan for this client, the nurse is most likely to include which nursing diagnosis?
Chronic low self-esteem
The nurse is preparing a client for a scheduled colonoscopy. The nurse should tell the client that before the procedure the client will do which action?
Cleanse the bowel with laxatives.
A nurse is caring for a client who is postoperative day 3 after an appendectomy. The client is not eating well and reports feeling bloated and slightly queasy. What should be the nurse's priority action?
Complete a thorough gastrointestinal focused assessment.
A 10-year-old client underwent an appendectomy 24 hours ago. They are awake, alert, and oriented. The client tells the nurse they are experiencing pain. They have a prescription for morphine 1 to 2 mg as needed for pain. What is the priority nursing action in managing the child's pain?
Determine the severity of the pain.
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone P.O. 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?
It has a short duration of action.
A client has massive bleeding from esophageal varices. In what order from first to last should the interprofessional team provide care for this client? All options must be used.
Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety.
A client is admitted to the hospital with a diagnosis of cholecystitis. The client has severe abdominal pain and nausea and has vomited 120 mL. Based on these data, which nursing action would have the highest priority at this time?
Manage the pain.
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. What should the nurse do next?
Place the client on nothing-by-mouth (NPO) status.
A client admitted to the hospital with peptic ulcer disease tells the nurse about having black, tarry stools. What should the nurse do?
Report the finding to the health care provider (HCP).
A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step?
Read the consent form to the client and ask if there are any questions.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as
a canker sore of the oral soft tissues.
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note
anorexia, nausea, and vomiting.
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which problem is associated with cirrhosis of the liver?
ascites related to portal hypertension
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to
auscultate bowel sounds.
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?
autonomy
A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?
ineffective breathing pattern
The nurse should assess the client with severe diarrhea for which acid-base imbalance?
metabolic acidosis
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
oxygen saturation (SaO2) of 89%
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds the client very difficult to arouse. The diagnostic information which best explains the client's behavior is
subnormal serum glucose and elevated serum ammonia levels.
A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the unlicensed assistive personnel (UAP) to look for and report which symptom?
tarry stools
The health care provider (HCP) has prescribed bethanechol for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which adverse effect?
urinary urgency
A client with peptic ulcer disease is ordered aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with
water
A nurse is caring for a client with watery diarrhea and dehydration. Given the client's recent history of heavy antibiotic use, what interventions should the nurse consider?
wearing gown and gloves when working in the room
When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?
maintaining fluid balance
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.6 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?
"Atropine decreases salivation and gastric secretions."
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for which sign(s) or symptom(s)? Select all that apply.
-projectile vomiting -rapid onset of dehydration -increased bowel sounds
The nurse has made rounds on a team of clients. The nurse should discuss which client with the health care provider (HCP)?
a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular
The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. What information should the nurse give the client?
Avoid lifting items weighing more than 5 lb (2.3 kg).
A client who had an open appendectomy for a perforated appendix has an incision secured with adhesive strips. What instruction should the nurse give the client about caring for the incision?
Leave the adhesive strips in place until they fall off.
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?
Localized warmth is felt over the incisional area.
A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has
cirrhosis
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
clay-colored stools
During the evening shift on the day of a client's bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. What should the nurse do next?
Record the amount of drainage on the client's chart.
The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first?
Stop the flow of solution.
The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication?
Take it with a full glass (240 mL) of water.
A physician orders lactulose, 30 ml three times daily, for a client with cirrhosis to treat elevated serum ammonia level. The nurse will know that this medication is effective by which finding?
The client's level of consciousness (LOC) would improve.
A client develops chronic pancreatitis. The nurse should suggest which diet?
a low-fat, bland diet distributed over five to six small meals daily
After undergoing a liver biopsy, a client should be placed in which position?
right lateral decubitus position
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the healthcare facility. Which test result is most significant?
serum potassium level of [3 mEq/L (3.0 mmol/L)]
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. Which additional assessment finding will the nurse assess for?
severe abdominal pain with direct palpation or rebound tenderness
A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why the client's abdomen is swollen, making it very difficult to fasten their pants. How should the nurse respond to provide the most accurate explanation of the disease process?
"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels."
Which statement indicates that the client understands the home care of a colostomy?
"I should be able to establish a regular pattern of elimination with my colostomy."
A client who is recovering from gastric surgery is receiving IV fluids to be infused at 100 mL/hour. The IV tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number.
25
A client has 4000 mL excess fluid removed via paracentesis. When the nurse weighs the client after the procedure, how many kilograms is an expected weight loss? Record your answer in whole numbers.
4
A client has a newly created colostomy. After participating in a teaching session with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?
The client touches the altered body part.
A client is having an acute attack of diverticulitis. What should the nurse do first?
Assess the client for signs of peritonitis.
The nurse is teaching a client with stomatitis about managing oral discomfort. Which instruction is most appropriate?
Eat a soft, bland diet.
A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take?
Increase fluids.
Following abdominal surgery, the nurse is auscultating the client's abdomen for bowel sounds. Which is the correct procedure?
Listen for 5 minutes in all four quadrants to confirm the absence of bowel sounds.
A client with a well-managed ileostomy has the sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do?
Notify the health care provider (HCP).
When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 101.1°F (38.4°C), a heart rate of 116 bpm, and a respiratory rate of 26 breaths/min. The client has an intravenous (IV) infusion running at a keep-open rate. The nurse contacts the health care provider (HCP) and receives several prescriptions (see chart).
Obtain blood cultures.
When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?
The client passes flatus.
A client is diagnosed with pancreatitis. Which assessment would be of most concern to the nurse?
bluish discoloration in periumbilical area
A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for
diaphoresis, vomiting, and diarrhea.
A client who has ulcerative colitis says to the nurse, "I can't take this anymore; I'm constantly in pain, and I can't leave my room because I need to stay by the toilet. I don't know how to deal with this." Based on these comments, what judgment should the nurse make about what the client is experiencing?
difficulty coping
A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which finding indicates the client is ready to try a liquid diet?
has frequent bowel sounds.
A client who has been diagnosed with gastroesophageal reflux disease (GERD) has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which item from their diet?
hot chocolate
A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task?
initiating I.V. therapy, as ordered
A nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should
irrigate the NG tube gently with normal saline solution if ordered.
A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?
loss of 2.2 lb (1 kg) in 24 hours
A client has just returned from surgery for a gastrectomy. The nurse should position the client in which position?
low Fowler's
The nurse is caring for a client who has had a total gastrectomy for gastric cancer. Which finding indicates the client has met goals to obtain adequate nutrition 4 weeks after the surgery?
maintains nutrition through oral or parenteral feedings
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances?
metabolic acidosis
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?
metabolic alkalosis
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube on low continuous suction. Which acid-base imbalance is most likely to occur?
metabolic alkalosis
A client presents to the emergency department, reporting that they have been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances?
metabolic alkalosis and hypokalemia
A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. The client complains of feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help the client
onto the bedpan.
The nurse is assessing the client who had a gastric resection yesterday. Which finding indicates the development of a leaking anastomosis?
pain, fever, and abdominal rigidity
A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the physician's orders, which medication should the nurse administer?
paregoric 5 ml P.O.
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
positioning the client on the side with the knees flexed
What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved?
preparation for emergency surgery
The client with an exacerbation of ulcerative colitis is to be on bed rest with bathroom privileges. What will indicate to the nurse that being on bed rest has had the desired outcome? The client has:
slowed intestinal peristalsis.
What is an appropriate nursing goal for a client who has ulcerative colitis?
verbalizes the importance of small, frequent feedings
The nurse is reviewing the nurses' notes and lab reports for a client who is receiving total parenteral nutrition (TPN). Which finding is the best indication that the goals for TPN are being achieved for the client?
weight gain of 0.5 lb/day (0.2 kg/day)
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note
yellow sclerae.
A client's abdominal incision eviscerates. What should the nurse do first?
Cover the incision with a dressing moistened with sterile normal saline solution.
The nurse is teaching a client with peptic ulcer disease how to take sucralfate. Which statement indicates that the client understands how to take the medication?
"It's important that I take this drug on an empty stomach."
A client who is recovering from a subtotal gastrectomy experiences dumping syndrome and is to eat six small meals a day. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate?
"Most clients can resume their normal meal patterns in about 6 to 12 months."
A client who had a splenectomy yesterday has a nasogastric (NG) tube. What should the nurse assess to determine the effectiveness of the NG tube?
absence of abdominal distention
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the client appears to be having difficulty breathing. What should the nurse do first?
Determine whether the tube is obstructing the airway.
A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. What should the nurse tell the client?
"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding."
A client with cholecystitis has severe pain unrelieved by ibuprofen. The client feels nauseated. The nurse obtains the following vital signs: temperature 101.1°F (38.4°C); pulse 114 bpm; respirations 22 breaths/min; and blood pressure 142/90 mm Hg. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, what should the nurse recommend to the health care provider for this client?
a medication for severe pain
A client with liver and renal failure has severe ascites. On initial shift rounds, the primary nurse finds the indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, the nurse finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?
albumin
A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan?
discussing collaborative goals and involving the client in identifying and prioritizing important interventions
Which client requires immediate nursing intervention? The client who
presents with a rigid, boardlike abdomen.
A nurse is caring for a client with esophageal varices. A Sengstaken-Blakemore tube is successfully inserted to control bleeding. The nurse should:
provide the client with an emesis basin to expectorate secretions.
A nurse is caring for a client who has had paraplegia for 6 years. The client is admitted with a bleeding peptic ulcer. What would be a priority teaching concern for the nurse?
recommending foods included in a bland diet
