Gastrointestinal System Level 1 & 2

Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy?

1 Advancing the tube to the original insertion depth if the tube becomes dislodged. 2 Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. Correct3 Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. 4 Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period. Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.

A client has an adenocarcinoma of the colon. It is suspected that the cancer has metastasized, and a liver computed tomography (CT) scan with contrast medium has been prescribed. What would be appropriate for the nurse to include in the client's instructions?

1 After the procedure, the client will be on bed rest for six hours to prevent complications. 2 During the procedure, the client will experience some discomfort, but an analgesic will be prescribed. 3 During the procedure, the client will receive light sedation, and the client may be able to hear people talking. Correct4 Before the procedure, the client will be given an intravenous (IV) infusion, and the client must lie as still as possible for a period of time. Stating that the client will be given an IV infusion containing a contrast medium before the procedure and must lie as still as possible for a period of time is an accurate explanation of what the client can expect during the CT scan. It is not necessary to rest in bed for six hours. The procedure causes no physical pain, and an analgesic is not necessary. The client will be awake; neither sedation nor anesthesia is used with a CT scan.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history?

1 Any rectal cancer in the family Correct2 All foods eaten in the past 24 hours 3 Any recent extreme emotional stress 4 An upper respiratory infection in the past 10 days The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion?

1 Choking 2 Redness 3 Gagging Correct4 Cyanosis If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis; this is a serious problem that must be corrected immediately. Choking may occur as the tube passes through the back of the throat; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Facial flushing (floridity) may result if the client attempts to fight the passage of the tube; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Gagging may occur as the tube passes from the nasal passage through the pharynx; this commonly occurs with insertion of a nasogastric tube and is a temporary problem.

Immediately after a liver biopsy, a client is placed onto the right side. What rationale does the nurse give for this positioning?

1 Decrease pain to provide comfort 2 Support erythropoiesis to increase red blood cell production Correct3 Compress blood vessels to prevent bleeding 4 Expel fluid trapped in the biliary ducts to promote drainage Pressure applied to the puncture site compresses blood vessels, thereby preventing bleeding. This position may or may not be comfortable for the client. The right side-lying position will not increase red blood cell production. The right side-lying position will have little or no effect on biliary ducts.

The nurse understands that research demonstrates that malnutrition occurs in as many as 50% of hospitalized clients. The nurse should assess a postoperative client with anorexia for what sign of malnutrition?

1 Dependent edema 2 Spoon-shaped nails 3 Loose, decayed teeth Correct4 Delayed wound healing Delayed wound healing often is caused by a lack of nutrients, such as protein and vitamin C, in the diet. Dependent edema usually occurs with severe protein deficiency and heart failure. Spoon-shaped nails usually occur with iron deficiency anemia. Loose, decayed teeth usually indicate prolonged malnutrition.

The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet?

1 Ginger ale Correct2 Apple juice 3 Orange juice 4 Cola beverages Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation.

A nurse is providing instructions to a client who is scheduled for a colonoscopy. What drink does the client indicate should be avoided several days before the test if these instructions are understood?

1 Ginger ale Incorrect2 Apple juice 3 Lemon-lime soda Correct4 Cherry Kool-Aid Red drinks should be avoided to prevent staining of the bowel, which may cause erroneous results. Ginger ale is a clear soft drink that will not alter test results. Apple juice is an acceptable beverage that also may help to clear the bowel of stool. Lemon-lime soda is an acceptable drink; it is a clear liquid that will not alter test results. Topics

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery?

1 Infection caused by the excretion of feces 2 Injury caused by exposed intestinal mucosa 3 Altered bowel elimination caused by the ostomy Correct4 Limited water reabsorption caused by removal of intestine The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although the irritation of the skin by fecal material may result in an infection, this usually is not a life-threatening complication. Although the stoma should be protected from injury and altered bowel elimination is a concern, these are not life-threatening complications.

A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, what would the nurse expect to observe?

1 Melena Correct2 Steatorrhea 3 Hard, dry stool 4 Ribbon-shaped stool Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon.

A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period?

1 Offering psychological support 2 Monitoring the client's fluid balance Correct3 Keeping the client's respiratory passages patent 4 Providing a pad and pencil for writing messages A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation?

1 Presence of distention 2 Extent of weight gained 3 Amount of high-fiber food consumed Correct4 Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list?

2 Tomato juice, raisin bran cereal, and tea Correct3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee Applesauce, cream of wheat, and apple juice are bland foods that do not irritate the gastric mucosa. Orange juice, fried eggs, sausage, tomato juice, raisin bran cereal, tea, sliced oranges, and coffee are not bland; they may be irritating to the mucosal lining. Caffeine should be avoided.

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse?

Correct1 "Tell me more about what you are thinking." 2 "Products are available to limit this problem." 3 "This is a problem, but the surgery is necessary." 4 "Most people who have this surgery share this same concern." The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client's concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client's concerns.

A frantic parent calls stating their child has swallowed dish soap. What should the nurse advise?

Correct1 Call poison control. 2 Induce vomiting immediately. 3 Give syrup of ipecac, one tablespoon. 4 Give activated charcoal, and expect black stools for 24 hours. Advise the parent to call poison control immediately. Information as to what needs to be done for virtually every product is available. This would also be the fastest source for obtaining details for treatment. Inducing vomiting may cause further damage if the substance is caustic, such as Drano, or contains lye. Giving syrup of ipecac is no longer advised, and therefore the substance is not in most homes. Activated charcoal is given in an emergency facility.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is prescribed. After the liver biopsy, how often and for how long should the nurse take the client's vital signs?

Correct1 Every 15 minutes for two hours 2 Every 30 minutes for four hours 3 Every hour for 8 hours 4 Every 2 hours for 12 hours Every 15 minutes for two hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; two hours after the procedure the vital signs can be taken every 30 minutes instead of every 15 minutes if they are stable. Every hour for 8 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs. Every 2 hours for 12 hours is too infrequent and unsafe if hemorrhage is to be detected before shock occurs.

A client is diagnosed with cancer of the stomach and is scheduled for a partial gastrectomy. The teaching on postoperative care provided by the nurse should cover what topic?

Correct1 Gastric suction 2 Oxygen therapy 3 Fluid restriction 4 Urinary catheter After gastric surgery a nasogastric tube is in place for drainage of blood and gastric secretions that allow healing at the site of anastomosis. Oxygen is not required unless the client experiences a complication necessitating its administration. An IV to meet fluid needs and replace gastric losses is given to the average client. A urinary catheter may or may not be necessary.

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites?

Correct1 Impaired portal venous return 2 Impaired thoracic lymph channels 3 Excess production of serum albumin 4 Enhanced hepatic deactivation of aldosterone secretion The congested liver impairs venous return, leading to increased portal vein hydrostatic pressure and an accumulation of fluid in the abdominal cavity. Although lymph channels in the abdomen become congested, facilitating the leakage of plasma into the peritoneal cavity, it is primarily the increased portal vein hydrostatic pressure that causes the accumulation of fluid in the abdominal cavity. Increased serum albumin causes hypervolemia, not ascites. As fluid is trapped in the peritoneal cavity, circulating blood volume drops and aldosterone secretion increases, not decreases; aldosterone secretion is related to the renin-angiotensin system.

A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include in the rationale for this diet?

Correct1 Repairs tissues 2 Slows peristalsis 3 Corrects the anemia 4 Improves muscle tone Protein is required for the building and repair of intestinal tissues. Increased protein will not affect peristalsis significantly. Anemia may result from chronic bleeding; usually, it is corrected with increased iron intake. Muscle tone is affected by exercise or lack of exercise

A nurse is caring for a client with cholelithiasis. Which clinical manifestation does the nurse expect if the client develops obstructive jaundice?

Correct1 Yellow sclera 2 Pain on urination 3 Dark brown stools 4 Coffee-ground emesis Yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into blood; bilirubin is carried to all body regions, including skin and mucous membranes. Pain on urination is not associated with obstructive jaundice, but dark brown urine is. Pain is experienced in the right upper quadrant because of spasm of the gallbladder, whether or not biliary obstruction occurs. The stools are clay-colored, not brown, because bile pigments are not present in the gastrointestinal tract; the common bile duct is obstructed. Coffee-ground emesis indicates gastric bleeding; it is not a sign of cholelithiasis with obstructive jaundice.

A client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. What signs should the nurse expect when assessing the client? Select all that apply.

Correct1 Fever Correct2 Tachypnea 3 Hypertension Correct4 Abdominal rigidity 5 Increased bowel sounds The metabolic rate will be increased, and the temperature-regulating center in the hypothalamus resets to a higher than usual body temperature because of the influence of pyrogenic substances related to the peritonitis. Tachypnea results as the metabolic rate increases and the body attempts to meet cellular oxygen needs. With increased intraabdominal pressure, the abdominal wall will become rigid and tender. Hypovolemia and therefore hypotension, not hypertension, results because of a loss of fluid, electrolytes, and protein into the peritoneal cavity. Peristalsis and associated bowel sounds will decrease or be absent in the presence of increased intraabdominal pressure.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply.

Correct1 Oliguria 2 Lethargy Correct3 Irritability Correct4 Hypotension Incorrect5 Slurred speech Decreased blood flow to the kidneys leads to oliguria or anuria. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client?

Incorrect1 "Have your dinner completed by 6:00 PM tonight and then no food or fluids after that." 2 "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." Correct3 "Consume a light evening meal tonight and then no food or fluids after midnight." 4 "Eat lunch today and then do not drink or eat anything until after your surgery." By eating a light meal and eliminating food and fluids after midnight, complications are limited during and after surgery; these include aspiration, nausea, dehydration, and possible ileus. A large meal the evening before surgery may not clear before peristalsis is slowed by anesthesia, resulting in abdominal distention and discomfort after surgery. Clear liquids in the morning can cause nausea, vomiting, and aspiration. Fluids should not be withheld for more than eight hours to prevent dehydration. Not eating or drinking anything after lunch is an excessive amount of time to restrict food and fluids before surgery the next morning.