GI Preu U Questions

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make? "It is a body part that is least examined." "It is a part of the assessment of every client." "Your problem is in your mouth and not your abdomen." "Changes in the mouth can help explain why your condition is occurring."

"Changes in the mouth can help explain why your condition is occurring." Explanation: A complete assessment of the oral cavity is essential because many disorders, such as cancer, diabetes, and immunosuppressive conditions resulting from medication therapy or acquired immunodeficiency syndrome, may be manifested by changes in the oral cavity, including stomatitis. Assessment of the mouth is not done because it is the body part least examined. It is not assessed because it is a part of every assessment. The nurse has no way of knowing if the client's gastrointestinal problem is in the client's mouth.

A client is scheduled for magnetic resonance imaging (MRI). During the client teaching, what will the nurse discuss? "You must remove all jewelry but can wear your wedding ring." "You must be NPO for the day before the examination." "Do you experience any claustrophobia?" "The examination will take only 15 minutes."

"Do you experience any claustrophobia?" Explanation: MRI is a noninvasive technique that uses magnetic fields and radio waves to produce images of the area being studied. Clients must be NPO for 6 to 8 hours before the study and remove all jewelry and other metals. The examination takes 60 to 90 minutes and can induce feelings of claustrophobia, because the scanner is close fitting.

The nurse is caring for a client who reports new onset of diarrhea. Which of the following should the nurse ask this client? Select all that apply. "How long ago did the diarrhea start?" "Does the diarrhea appear to contain mucus?" "Does the diarrhea awaken you at night"? "Are you experiencing severe heartburn with the diarrhea?" "Have you noticed any blood in the diarrhea?"

"How long ago did the diarrhea start?" "Does the diarrhea appear to contain mucus?" "Does the diarrhea awaken you at night"? "Have you noticed any blood in the diarrhea?" Explanation: Diarrhea is considered "acute" when lasting less than 14 days and persistent when occurring for 14 to 30 days. It is considered chronic if lasting longer than 30 days. The nurse should question the client concerning the characteristics of the stool—for example, volume; frequency; consistency; the appearance of mucus, oily substances, or blood; and the time of day (e.g., if diarrhea occurs only during the daytime hours or if it awakens the client at night). Severe heartburn is not associated with diarrhea.

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding? 30 minutes 1 hour 90 minutes 2 hours

1 hour Explanation: The semi-Fowler position is necessary for a nasogastric (NG) feeding, with the client's head elevated at least 30 to 45 degrees to reduce the risk for reflux and pulmonary aspiration. This position is maintained for at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

The nurse is caring for a client with oral cancer who reports mouth sensitivity. The client asks the nurse what might be done. Select all that apply. "I can arrange a nutritional consultation." "Cold liquids may help soothe the sensitivity." "An anesthetic mouthwash may be used, but I will need to consult with the primary provider." "A special diet may be necessary based on your ability to chew and swallow." "Your health care provider may prescribe a systemic analgesic for pai

"I can arrange a nutritional consultation." "An anesthetic mouthwash may be used, but I will need to consult with the primary provider." "A special diet may be necessary based on your ability to chew and swallow." "Your health care provider may prescribe a systemic analgesic for pain relief if necessary." Explanation: The nurse should include the statements, "I can arrange a nutritional consultation," "An anesthetic mouthwash may be used, but I will need to consult with the primary provider," "A special diet may be necessary based on your ability to chew and swallow," and "Your doctor may prescribe a systemic analgesic for pain relief if necessary." These statements describe the management of the plan of care for the client with severe mouth sensitivity. The statement, "Cold liquids may help soothe the sensitivity," should not be included, because cold and hot liquids may increase the discomfort of sensitive oral tissue

When preparing a client for magnetic resonance imaging (MRI) of the abdomen, which statement would indicate the need to notify the health care provider? "I haven't had anything to eat or drink since midnight last night." "I really don't like to be in small, enclosed spaces." "I left all my jewelry and my watch at home." "I brought earphones to shut out the loud noise."

"I really don't like to be in small, enclosed spaces." Explanation: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the health care provider about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. The machine makes loud repetitive noises while the test is in progress, so earphones may be helpful.

A client is scheduled for an ultrasound of the abdomen. Which statement indicates that teaching provided to the client to prepare for the test was effective? "I will take an over-the-counter enema before the test." "I will not eat or drink for 8 to 12 hours before the test." "I will ingest a clear liquid diet for 3 days before the test." "I will take medications to reduce gastric acid before the test."

"I will not eat or drink for 8 to 12 hours before the test." Explanation: Ultrasonography is a noninvasive diagnostic technique in which high-frequency sound waves are passed into internal body structures, and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities. It is particularly useful in the detection of an enlarged gallbladder or pancreas, or the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. The client should be instructed to fast for 8 to 12 hours before the test to decrease the amount of gas in the bowel. Enemas are not needed before an abdominal ultrasound. A clear liquid diet is not needed before the test. Medications to reduce gastric acid are not required before the test.

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment? "I'll eat three large meals every day without any food restrictions." "I'll lie down immediately after a meal." "I'll gradually increase the amount of heavy lifting I do." "I'll eat frequent, small, bland meals that are high in fiber."

"I'll eat frequent, small, bland meals that are high in fiber." Explanation: In hiatal hernia, the upper portion of the stomach protrudes into the chest when intra-abdominal pressure increases. To minimize intra-abdominal pressure and decrease gastric reflux, the client should eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver). Eating three large meals daily would increase intra-abdominal pressure, possibly worsening the hiatal hernia. The client should avoid spicy foods, alcohol, and tobacco because they increase gastric acidity and promote gastric reflux. To minimize intra-abdominal pressure, the client shouldn't recline after meals, lift heavy objects, or bend.

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers: "It tells the physician what type of cancer is present." "It indicates if a cancer is present." "It determines functionality of the liver." "It detects a protein normally found in the blood."

"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate? "It is a vent that prevents backflow of the secretions." "It acts as a siphon, pulling secretions into the clear tubing." "It helps regulate the pressure on the suction machine." "It works as a marker to make sure that the tube stays in place."

"It is a vent that prevents backflow of the secretions." Explanation: The blue part of the Salem sump tube vents the larger suction-drainage tube to the atmosphere and, when kept above the patient's waist, prevents reflux of gastric contents through it. Otherwise it acts as a siphon. A gauge on the suction device regulates the pressure of the device. The tube has markings on it to aid in measurement.

The nurse asks a client to point to where pain is felt. The client asks why this is important. What is the nurse's best response? "If the health care provider massages over the exact painful area, the pain will disappear." "The area may determine the severity of the pain." "This determines the pain medication to be ordered." "Often the area of pain is referred from another area."

"Often the area of pain is referred from another area." Explanation: Pain can be a major symptom of disease. The location and distribution of pain can be referred from a different area. If a client points to an area of pain and has other symptoms associated with a certain disease, this is valuable information for treatment.

A patient has a gastric sump tube attached to low intermittent suction. The nurse empties the suction collection chamber and records an output of 320 mL for this 8-hour shift. The record shows that the tube had been irrigated with 20 mL of normal saline twice this shift. What would be the actual output of the gastric sump tube?

280 Explanation: The output measured includes the two 20 mL irrigations. To determine the actual output, the nurse would subtract the amount of irrigation used (in this case 40 mL total) from the total output (in this case 320 mL) and arrive at an output of 280 mL.

When completing a nutritional assessment of a patient who is admitted for a GI disorder, the nurse notes a recent history of dietary intake. This is based on the knowledge that a portion of digested waste products can remain in the rectum for how many days after a meal is digested? 1 day 2 days 3 days 4 days

3 days Explanation: As much as 25% of the waste products from a meal may still be in the rectum 3 days after a meal is ingested.

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs? 1 2 4 6

6 Explanation: Determining the pH of the tube aspirate is a more accurate method of confirming tube placement than is maintaining tube length or visually assessing tube aspirate. The pH method can also be used to monitor the advancement of the tube into the small intestine. The pH of gastric aspirate is acidic (1 to 5), typically less than 4. The pH of intestinal aspirate is approximately 6 or higher, and the pH of respiratory aspirate is more alkaline.

The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.

6 Explanation: Step 1: 2 × 8 oz = 16 oz Step 2: 1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? 4 p.m. to 6 p.m. 6 p.m. to 8 p.m. 8 p.m. to 10 p.m. 10 p.m. to 12 a.m.

6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.

A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours? 20 to 40 mL 50 to 75 mL 80 to 120 mL 160 to 200 mL

80 to 120 mL Explanation: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? Wear tight-fitting clothing Avoid eating or drinking 2 hours before bedtime Elevate the foot of the bed on 6- to 8-inch blocks Eat a low-carbohydrate diet

Avoid eating or drinking 2 hours before bedtime Explanation: The client should be advised to avoid eating or drinking 2 hours before bedtime. The client should not recline with a full stomach. The client should be instructed to avoid caffeine, beer, milk, and foods containing peppermint or spearmint, and to eat a low-fat diet. The client should be instructed to elevate the head, not the foot, of the bed on 6- to 8-inch blocks. The client should avoid tight-fitting clothes.

The nurse is caring for a client recovering from a colonoscopy. Which assessment finding will the nurse expect in the client after the procedure? Fever Rectal bleeding Abdominal cramps Abdominal distention

Abdominal cramps Explanation: After the procedure, clients are maintained on bed rest until fully alert. Some clients have abdominal cramps caused by increased peristalsis stimulated by the air insufflated into the bowel during the procedure. Fever, rectal bleeding, and abdominal distention are symptoms of bowel perforation and should be immediately reported to the health care provider.

The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment? Drowsiness Abdominal distention Sore throat Thirst

Abdominal distention Explanation: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.

The nurse is to insert a postpyloric feeding tube. How can the nurse aid in placement of the tube past the pylorus? Administer prescribed metoclopramide. Have the client lay on the left side. Assist the client to drink 8 ounces of water. Instruct the client to swallow several times.

Administer prescribed metoclopramide. Explanation: Metoclopramide (Reglan) is administered to increase peristalsis of the feeding tube into the duodenum. Placing the client on the right side, not the left side, helps to facilitate movement and placement. Having the client swallow or even to drink water facilitates placement of the tube past the epiglottis, not into the duodenum.

The nurse is caring for a patient who has dumping syndrome from high-carb foods being administered over a period of fewer than 20 minutes. What is a nursing measure to prevent or minimize the dumping syndrome? Administer the feeding at a warm temperature to decrease peristalsis. Administer the feeding with about 100 mL of fluid to dilute the high-carbohydrate concentration. Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time.

Administer the feeding with the patient in semi-Fowler's position to decrease the effect of gravity on transit time. Explanation: The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: -Advise the patient to remain in semi-Fowler's position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. -Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. -Administer feedings at room temperature, not at a warm temperature, because temperature extremes stimulate peristalsis. -Administer feeding by continuous drip (if tolerated), rather than by bolus, to prevent sudden distention of the intestine. -Instill the minimal amount of water needed to flush the tubing before and after a feeding, not to dilute the formula but because fluid given with a feeding increases intestinal transit time.

A client 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 client is alert. What is the client's priority need at this time? Emotional support from visitors and staff An effective means of communicating with the nurse Referral to a speech therapist Dietary teaching focused on consistency of food and frequency of feedings

An effective means of communicating with the nurse Explanation: Verbal communication may be impaired by radical surgery for oral cancer. Emotional support and dietary teaching are critical aspects of the plan of care; however, the client's ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the client's rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care.

A client in the emergency department reports that a piece of meat became stuck in the throat. The nurse notes the client is anxious with RR at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? Assess lung sounds bilaterally. Administer prescribed morphine IV. Obtain consent for the esophagogastroscopy. Suction the oral cavity of the client.

Assess lung sounds bilaterally. Explanation: All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by Assessing lung sounds Providing fluids to drink Preparing for a barium swallow Administering the prescribed analgesic

Assessing lung sounds Explanation: Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

An older adult client is admitted to an acute care facility for treatment of an acute flare-up of a chronic gastrointestinal condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the gastrointestinal tract. Which age-related change increases the risk of anemia? Atrophy of the gastric mucosa Decrease in intestinal flora Increase in bile secretion Dulling of nerve impulses

Atrophy of the gastric mucosa Explanation: Atrophy of the gastric mucosa reduces hydrochloric acid secretion; this, in turn, impairs absorption of iron and vitamin B12, increasing the risk of anemia as a person ages. A decrease in hydrochloric acid increases, not decreases, intestinal flora; as a result, the client is at increased risk for infection, not anemia. A reduction, not increase, in bile secretion may lead to malabsorption of fats and fat-soluble vitamins. Dulling of nerve impulses associated with aging increases the risk of constipation, not anemia.

A client is receiving a parenteral nutrition admixture and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse? Stops the admixture while the fat emulsion infuses Starts a peripheral IV site to administer the fat emulsion Attaches the fat emulsion tubing to a Y connector close to the infusion site Connects the tubing for the fat emulsion above the 1.5 micron filter

Attaches the fat emulsion tubing to a Y connector close to the infusion site Explanation: An intravenous fat emulsion is attached to a Y connector close to the infusion site. The fat emulsion is administered simultaneously with the parenteral nutrition admixture. A separate peripheral IV site is not necessary. The fat emulsion is not administered through a filter.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to Apply water-based lubricant to the nares daily. Auscultate lung sounds every 4 hours. Inspect the nose daily for skin irritation. Change the nasal tape every 2 to 3 days.

Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

The nurse is caring for a client who is scheduled for a urea breath test to detect for Helicobacter pylori as a reason for gastric distress. Which instruction(s) will the nurse provide to the client to prepare for this test? Select all that apply. Take antibiotics prior to the test. Take cimetidine 24 hours before the test. Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test. Take famotidine for 1 week before the test.

Avoid bismuth subsalicylate before the test. Do not take proton pump inhibitors before the test. Urea breath tests detect the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach and cause peptic ulcer disease. Prior to urea breath testing, the client should be instructed to avoid antibiotics and bismuth subsalicylate for 1 month. Proton pump inhibitors should be avoided for 2 weeks. Cimetidine and famotidine should be avoided for 24 hours before the test.

When assisting with preparing a client scheduled for a barium swallow, which of the following would be appropriate to include? Avoid smoking for at least 12 to 24 hours before the procedure. Take vitamin K before the procedure. Take three cleansing enemas before the procedure. Avoid the intake of red meat before the procedure.

Avoid smoking for at least 12 to 24 hours before the procedure. Explanation: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.

Which of the following is the most definitive means of assessing for liver disease? Biopsy Paracentesis Cholecystography Ultrasonography

Biopsy Explanation: Liver biopsy is the most effective means of diagnosing liver disease. Guided liver biopsy can be conducted using laparoscopy, the insertion of a fiberoptic endoscope through a small abdominal incision. Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Cholecystography and ultrasonography may be used to detect gallstones. Ultrasonography may also be used to visualize the liver and diagnose conditions such as liver fibrosis; noninvasive techniques such as this can reduce the need for liver biopsy.

The nurse is to obtain a stool specimen from a client who reported that he is taking iron supplements. The nurse would expect the stool to be which color? Dark brown Green Red Black

Black Explanation: Ingestion of iron can cause the stool to turn black. Meat protein causes stool to appear dark brown. Ingestion of large amounts of spinach may turn stool green while ingestion of carrots and beets may cause stool to turn red.

A client reports a history of bleeding hemorrhoids to the nurse. Which observation supports the client's statement? Hard, dry stool Dark red stool Black tarry stool Blood streaks on stool

Blood streaks on stool Explanation: Blood in the stool can present in various ways and must be investigated. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue. Hard, dry stool occurs in constipation. If blood is shed in sufficient quantities into the upper GI tract, it produces a dark red color, a tarry-black color, or melena.

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition? Halitosis Zenker diverticulum Boerhaave syndrome Periapical abscess

Boerhaave syndrome Explanation: Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? Use a hard-bristled toothbrush. Rinse with an alcohol-based solution. Brush and floss daily. Continue with the usual diet.

Brush and floss daily. Explanation: The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? Bowel disease of unknown origin Cancer Inflammatory bowel disease Occult bleeding

Cancer Explanation: This procedure is used commonly as a diagnostic aid and screening device. It is most frequently used for cancer screening and for surveillance in patients with previous colon cancer or polyps. In addition, tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. Other uses of colonoscopy include the evaluation of patients with diarrhea of unknown cause, occult bleeding, or anemia; further study of abnormalities detected on barium enema; and diagnosis, clarification, and determination of the extent of inflammatory or other bowel disease.

A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium? Small bowel series Computer tomography Colonoscopy Upper GI series

Colonoscopy Explanation: A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series. - A colonoscopy is a procedure that lets your health care provider check the inside of your entire colon (large intestine). The procedure is done using a long, flexible tube called a colonoscope. The tube has a light and a tiny camera on one end. It is put in your rectum and moved into your colon.

A client's new onset of dysphagia has required insertion of a nasogastric (NG) tube for feeding. What intervention should the nurse include in the client's plan of care? Confirm placement of the tube prior to each medication administration. Have the client sip cool water to stimulate saliva production. Keep the client in a low Fowler position when at rest. Connect the tube to continuous wall suction when not in use.

Confirm placement of the tube prior to each medication administration. Explanation: Each time liquids or medications are administered, and once a shift for continuous feedings, the tube must be checked to ensure that it remains properly placed. If the NG tube is used for decompression, it is attached to intermittent low suction. During the placement of a NG tube the client should be positioned in a Fowler's position. Oral fluid administration is contraindicated by the client's dysphagia.

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication? A cardiac dysrhythmia Fluid volume deficit Mucous membrane irritation Pulmonary complications

Fluid volume deficit Explanation: Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate.

A nurse is caring for a client receiving parenteral nutrition at home. The client was discharged from the acute care facility 4 days ago. What would the nurse include in the client's plan of care? Select all that apply. Daily weights Intake and output monitoring Calorie counts for oral nutrients Daily transparent dressing changes Strict bedrest

Daily weights Intake and output monitoring Calorie counts for oral nutrients For the client receiving parenteral nutrition at home, the nurse would obtain daily weights initially, decreasing them to two to three times per week once the client is stable. Intake and output monitoring also is necessary to evaluate fluid status. Calorie counts of oral nutrients are used to provide additional information about the client's nutritional status. Transparent dressings are changed weekly. Activity is encouraged based on the client's ability to maintain muscle tone. Strict bedrest is not appropriate.

Prior to a client's scheduled jejunostomy, the nurse is performing the preoperative assessment. What goal should the nurse prioritize during the preoperative assessment? Determining the client's nutritional needs Determining that the client fully understands the postoperative care required Determining the client's ability to understand and cooperate with the procedure Determining the client's ability to cope with an altered body image

Determining the client's ability to understand and cooperate with the procedure Explanation: The major focus of the preoperative assessment is to determine the client's ability both to understand and cooperate with the procedure. Body image, nutritional needs, and postoperative care are all important variables, but they are not the main focuses of assessment during the immediate preoperative period.

The nurse is caring for a client receiving enteral nutrition with a standard polymeric formula. For which reason will the nurse question using this formula for the client? History of diverticulitis Treatment for internal hemorrhoids Polyps removed during a colonoscopy Diagnosed with malabsorption syndrome

Diagnosed with malabsorption syndrome Explanation: Various tube feeding formulas are available commercially. Polymeric formulas are the most common and are composed of protein (10% to 15%), carbohydrates (50% to 60%), and fats (30% to 35%). Standard polymeric formulas are undigested and require that the client has relatively normal digestive function and absorptive capacity. This type of formula should be questioned because the client is diagnosed with malabsorption syndrome. There is no reason to question the client for a history of diverticulitis, treatment for internal hemorrhoids, or removal of polyps.

Which is the primary symptom of achalasia? Difficulty swallowing Chest pain Heartburn Pulmonary symptoms

Difficulty swallowing Explanation: The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

A client receiving tube feedings to the duodenum develops nausea, cramping, and diarrhea. For which condition should the nurse plan care for this client? Diverticulosis Paralytic ileus Dumping syndrome Small bowel obstruction

Dumping syndrome Explanation: Osmolality is an important consideration for clients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. When a concentrated solution of high osmolality entering the stomach is taken in quickly or in large amounts, the small intestines expand and water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The client may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, which indicates dumping syndrome. The client's symptoms are not caused by a diverticulosis, paralytic ileus, or a small bowel obstruction.

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? Dysphagia Malnutrition Pain Regurgitation of food

Dysphagia Explanation: Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention? Place the client in a supine position. Elevate the head of the bed 90 degrees during meals. Encourage the client to remove dentures. Encourage thin liquids for dietary intake.

Elevate the head of the bed 90 degrees during meals. Explanation: The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to Check the residual volume before the feeding. Accurately assess the amount of fluid infused. Elevate the head of the bed to 45 degrees. Change the tube feeding container and tubing.

Elevate the head of the bed to 45 degrees. Explanation: All the options are things that the nurse will do when administering a cyclic tube feeding. Elevating the head of the bed to 30 to 45 degrees assists in preventing aspiration into the lungs. This is a priority according to Maslow's hierarchy of needs.

The nurse is teaching a client with GERD about how to reduce reflux. What should the nurse include in the teaching? Select all that apply. Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Encourage the client to eat later in the day before bedtime rather than early in the morning. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly.

Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly. The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.

A client is scheduled to receive a 25% dextrose solution of parenteral nutrition. What actions are a priority for the nurse to perform prior to administration? Select all that apply. Assess for patency of the peripheral intravenous site Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Administer the intravenous antibiotic in the same tubing as the parenteral nutrition Place a 1.5-micron filter on the tubing

Ensure availability of an infusion pump Ensure completion of baseline monitoring of the complete blood count (CBC) and chemistry panel Place a 1.5-micron filter on the tubing Parenteral nutrition with dextrose concentrations of greater than 10% should not be administered through peripheral veins. An infusion pump should always be used for the administration of parenteral nutrition. Standing orders are initiated that include monitoring of CBC and chemistry panel prior to the start of parenteral nutrition. Medications should not be administered in the same IV line as the parenteral nutrition because of potential incompatibilities with the components of the nutritional solution. A special filter (1.5-micron filter) is used with parenteral nutrition.

A client has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. What is the nurse's best response to this change in health status? Ensure that none of the client's visitors have an infection. Arrange for a diet that is high in protein and low in fat. Administer colony stimulating factors (CSFs) as prescribed. Prepare to administer chemotherapeutics as prescribed.

Ensure that none of the client's visitors have an infection. Explanation: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the client's immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.

The nurse is investigating a client's report of pain in the duodenal area. Where should the nurse perform the assessment? Epigastric area and consider possible radiation of pain to the right subscapular region Hypogastrium in the right or left lower quadrant Left lower quadrant Periumbilical area, followed by the right lower quadrant

Epigastric area and consider possible radiation of pain to the right subscapular region Explanation: Indigestion is an imprecise term that refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation; it occurs in approximately 25% of the adult population

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely? Excess fluid volume Risk for imbalanced nutrition, more than body requirements Deficient fluid volume Impaired urinary elimination

Excess fluid volume Explanation: The patient's intake and output record reflects a greater intake than output, suggesting excess fluid volume. No information suggests that the patient's nutritional balance is at risk, even with nasogastric tube feedings. Deficient fluid volume would be appropriate if the patient's output exceeded input. No information indicates that the patient is experiencing difficulty with urination.

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries? Exhibiting hemoglobin A1C 8.2 Drinking fluoridated water Eating fruits and cheese in diet Using a soft-bristled toothbrush

Exhibiting hemoglobin A1C 8.2 Explanation: Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

A nurse has obtained an order to remove a client's NG tube that was placed for feeding. What is the nurse's best initial action? Assess the client's appetite. Assist the client into a supine position. Apply topical anesthetic to the client's nares as prescribed. Explain the process clearly to the client.

Explain the process clearly to the client. Explanation: The process should be explained to the client before removal. A client should not normally be supine with an NG tube in place and anesthetic is not normally prescribed. Removal is not contingent on the client's appetite.

A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about? Extrapyramidal Peptic ulcer disease Gastric slowing Nausea

Extrapyramidal Explanation: Metoclopramide (Reglan) is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

When assessing whether a client is a candidate for home parenteral nutrition, what would be important to address? Select all that apply. Family support Telephone access Marital status Motivation for learning Health status

Family support Telephone access Motivation for learning Health status Ideal candidates for home parenteral nutrition are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for parenteral nutrition, and are highly motivated and fairly self-sufficient. Additional areas to consider include the client's ability to learn, availability of family interest and support, adequate finances, and the physical plan of the home including access to water, electricity, refrigeration, and telephone. The client's marital status is not important.

Postoperatively, a client with a radical neck dissection should be placed in which position? Supine Fowler Prone Side-lying

Fowler Explanation: The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

A client with a diagnosis of late-stage Alzheimer disease has begun supplemental feedings through a nasogastric (NG) tube. Which of the nurse's assessments addresses this client's most significant potential complication of feeding? Frequent assessment of the client's abdominal girth Assessment for hemorrhage from the nasal insertion site Frequent lung auscultation Frequent monitoring of the frequency and character of bowel movements

Frequent lung auscultation Explanation: Aspiration is a risk associated with tube feeding; this risk may be exacerbated by the client's cognitive deficits. Consequently, the nurse should auscultate the client's lungs and monitor oxygen saturation closely. Bowel function is important, but the risk for aspiration is a priority. Hemorrhage is highly unlikely and the client's abdominal girth is not a main focus of assessment.

A few hours after eating hot and spicy chicken wings, a client presents with lower chest pain. He wonders if he is having a heart attack. How should the nurse proceed first? Further investigate the initial complaint. Explain that fatty foods can mimic chest pain. Call for an immediate electrocardiogram. Administer an over-the-counter antacid tablet.

Further investigate the initial complaint. Explanation: While fatty foods can cause discomfort similar to chest pain, the nurse must fully assess all the client's symptoms. Investigation of chief complaint begins with a complete history. The underlying cause of pain influences the characteristics, duration, pattern, location, and distribution of pain.

A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Gastroesophageal reflux disease Peptic ulcer with melena Diverticulitis with perforation Gastritis

Gastroesophageal reflux disease Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

What is the reason that gastrostomy feedings are preferred to NG feedings in the comatose patient? Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Digestive process occurs more rapidly because the feedings do not have to pass through the esophagus. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely.

A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document? Aphthous stomatitis Nicotine stomatitis Erythroplakia Hairy leukoplakia

Hairy leukoplakia Explanation: Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? Slow the current infusion rate so that it will last until the new solution arrives. Hang a solution of dextrose 10% and water until the new solution is available. Have someone go to the pharmacy to obtain the new solution.

Hang a solution of dextrose 10% and water until the new solution is available. Explanation: The infusion rate of the solution should not be increased or decreased; if the solution is to run out, a solution of 10% dextrose and water is used until the next solution is available. Having someone go to the pharmacy would be appropriate, but there is no way to determine if the person will arrive back before the solution runs out. Starting another infusion would be inappropriate. Additionally, the infusion needs to be maintained through the central venous access device to maintain patency.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician? High epigastric pain and/or discomfort Crackles that clear after coughing Serous drainage on the dressing Temperature of 99.0°F (37.2°C)

High epigastric pain and/or discomfort Explanation: The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.

A client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test? History of allergies Presence of a cochlear implant Last use of an oral laxative Current list of prescribed medications

History of allergies Explanation: A CT scan provides cross-sectional images of abdominal organs and structures. A CT scan may be performed with or without oral or intravenous (IV) contrast, but the enhancement of the study is greater with the use of a contrast agent. A common risk from IV contrast agents is allergic reactions; therefore, the client must be screened for this risk. Any allergies to contrast agents, iodine, or shellfish must be determined before administration of a contrast agent. Clients allergic to the contrast agent may be premedicated with a corticosteroid and antihistamine. Therefore, a history of allergies must be completed before the test. Assessing for the presence of a cochlear implant is recommended before magnetic resonance imaging (MRI), but not before a CT scan. The last use of an oral laxative and current list of prescribed medications are not required before a CT scan of the abdomen.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds? Normal Hypoactive Hyperactive Borborygmi

Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective (Li, Wang, & Ma, 2012).

A nurse is performing health education with a client who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis? Ineffective Tissue Perfusion Impaired Skin Integrity Aspiration Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements Explanation: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a person's nutritional status. Dental caries do not typically affect the client's tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon returning to the nursing unit, what does the nurse identify as the client goal? Recovery from the general anesthesia Decrease in nausea and vomiting Increase in the amount of fluids Ambulates independently

Increase in the amount of fluids Explanation: The client, returning from an upper gastrointestinal series, needs to increase fluids in an effort to eliminate the barium from the body through a bowel movement. General anesthesia is not used. The client typically does not have nausea and vomiting following the procedure. If the client is able to ambulate independently prior to the procedure, the client will be able to ambulate independently following.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Increasing difficulty in swallowing Sensation of a mass in throat Foul breath Hiccups

Increasing difficulty in swallowing Explanation: The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as Impaired tissue integrity related to surgical intervention Imbalanced nutrition: less than body requirements, related to treatment Risk for infection related to surgical intervention Ineffective airway clearance related to obstruction by mucus

Ineffective airway clearance related to obstruction by mucus Explanation: All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.

The client is receiving a 25% dextrose solution of parenteral nutrition. The infusion machine is beeping, and the nurse determines the intravenous (IV) bag is empty. The nurse finds there is no available bag to administer. What is the priority action by the nurse? Request a new bag from the pharmacy department. Infuse a solution containing 10% dextrose and water. Flush the line with 10 mL of sterile saline. Catch up with the next bag when it arrives.

Infuse a solution containing 10% dextrose and water. Explanation: If the parenteral nutrition solution runs out, a solution of 10% dextrose and water is infused to prevent hypoglycemia. The nurse would then order the next parenteral nutrition bag from the pharmacy. Flushing a peripherally inserted catheter is usually prescribed every 8 hours or per hospital established protocols. It is not the most important activity at this moment. The infusion rate should not be increased to compensate for fluids that were not infused, because hyperglycemia and hyperosmolar diuresis could occur.

A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test? Ingest nothing by mouth after midnight. Eat a clear liquid breakfast before the test. Withhold oral medications for 24 hours before the test. Avoid products containing aspirin for a week before the test.

Ingest nothing by mouth after midnight. Explanation: An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent such as barium. To prepare for the test, the client should be instructed to ingest nothing after midnight before the test. Clear liquids are not permitted the morning of the test. Most oral medications are withheld the morning of the test, but not for 24 hours before. There is no reason to avoid products containing aspirin for a week before the test.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is Coiling in the client's mouth Irritating the epiglottis Inserted into the lungs Passing into the esophagus

Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nasogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.

The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first? Palpation Inspection Auscultation Percussion

Inspection Explanation: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.

Results of a client barium swallow suggest that the client has GERD. The nurse is planning health education to address the client's knowledge of this new diagnosis. Which of the following should the nurse encourage? Eating several small meals daily rather than 3 larger meals Keeping the head of the bed partially elevated Drinking carbonated mineral water rather than soft drinks Avoiding food or fluid intake after 6:00 PM

Keeping the head of the bed partially elevated Explanation: The client with GERD is encouraged to elevate the head of the bed at least 30 degrees. Frequent meals are not specifically encouraged and the client should avoid food and fluid within 2 hours of bedtime. All carbonated beverages should be avoided.

A focused GI assessment begins with a complete history and physical examination. Identify the quadrant of the abdomen to be palpated or percussed for a patient with pancreatitis. Right upper Right lower Left upper Left lower

Left upper Explanation: The pancreas, which is about 6 inches long, is located behind the stomach in the upper left side of the body.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure? Sigmoid colon Appendix Spleen Liver

Liver Explanation: The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to? Helping the client cope with body image changes Ensuring adequate nutrition Maintaining a patent airway Preventing injury

Maintaining a patent airway Explanation: Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is: Make a notation on the call light system that the client cannot speak. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. Provide oxygen without humidity through the tracheostomy tube. Encourage the client to position himself on his side.

Make a notation on the call light system that the client cannot speak. Explanation: The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid) Esomeprazole (Nexium)

Metoclopramide (Reglan) Explanation: Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Monitoring the feeding closely. Increasing the feeding rate. Lowering the head of the bed. Flushing the feeding tube.

Monitoring the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.

A nurse is giving a client barium swallow test. What is the most important assessment a nurse would make to ensure that a client does not retain any barium after a barium swallow? Placing any stool passed in a specific preservative. Monitoring the stool passage and its color. Observing the color of urine. Monitoring the volume of urine.

Monitoring the stool passage and its color. Explanation: Monitoring stool passage and its color will ensure that the client remains barium free following a barium swallow test. The white or clay color of the stool would indicate barium retention. The stool should be placed in a special preservative if the client undergoes a stool analysis. Observing the color and volume of urine will not ensure that the client is barium free because barium is not eliminated through urine but through stool.

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? Nystatin Cephalexin Fluocinolone acetonide oral base gel Acyclovir

Nystatin Explanation: Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

The nurse has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply. Observe for respiratory distress. Measure pH of feeding tube aspirates. Auscultate. Monitor aspirate for sudden change in amount. Mark the tube at the exit site. Obtain radiographic confirmation.

Observe for respiratory distress. Measure pH of feeding tube aspirates. Monitor aspirate for sudden change in amount. Mark the tube at the exit site. Obtain radiographic confirmation. The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.

A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered? Instruct the client to have low-residue meals. Allow the client to ingest fat-free meal. Permit the client to drink only clear liquids. Provide saline gargles to the client.

Permit the client to drink only clear liquids. Explanation: After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.

The nurse is caring for a client who has a gastrostomy tube feeding. Upon initiating care, the nurse aspirates the gastrotomy tube for gastric residual volume (GRV) and obtains 200 mL of gastric contents. What is the priority action by the nurse? Discontinue the infusion. Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Remove the aspirated fluid and do not reinstill. Dilute the gastric tube feeding solution with water and continue the feeding.

Place the client in a semi-Fowler's position with the head of the bed at 45 degrees. Explanation: Feedings and medications should always be administered with the client in the semi-Fowler's position, and the client's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained at all times for clients receiving continuous tube feedings.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action? Place the client in the Fowler's position. Administer morphine for report of pain. Provide feeding through the gastrostomy tube. Empty the Jackson-Pratt device (portable drainage device).

Place the client in the Fowler's position. Explanation: All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.

A nurse is admitting a client to the postsurgical unit following a gastrostomy. When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? Premature removal of the G tube Bowel perforation Constipation Development of peptic ulcer disease (PUD)

Premature removal of the G tube Explanation: A significant postoperative complication of a gastrostomy is premature removal of the G tube. Constipation is a less immediate threat and bowel perforation and PUD are not noted to be likely complications.

The nurse is caring for a client on chemotherapy who is recovering from surgery for oral cancer. Which interventions will the nurse add to this client's plan of care? Select all that apply. Prevent infection Maintain a patent airway Ensure adequate nutritional intake Provide a mechanism to communicate Prevent the development of stomatitis

Prevent infection Maintain a patent airway Ensure adequate nutritional intake Provide a mechanism to communicate Prevent the development of stomatitis

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? Complete blood count (CBC) Prothrombin time (PT) Blood chemistry Erythrocyte sedimentation rate (ESR)

Prothrombin time (PT) Explanation: The client must have coagulation studies (PT, aPTT, INR, platelet count) before the procedure because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.

A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is: H2-receptor antagonists. Antispasmodics Proton pump inhibitors. Antacids

Proton pump inhibitors. Explanation: Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an): Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm.

Protrusion of the upper stomach into the lower portion of the thorax. Explanation: It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client? Urge the client to regularly rinse the mouth with tap water. Recommend that the client drink a small glass of alcohol at the end of the day to kill germs. Provide the client with an irrigating solution of baking soda and warm water. Regularly wipe the outside of the client's mouth to prevent germs from entering.

Provide the client with an irrigating solution of baking soda and warm water. Explanation: If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.

A nurse is writing a care plan for a client with a nasogastric tube in place for gastric decompression. Which risk nursing diagnosis is the most appropriate component of the care plan? Risk for Excess Fluid Volume Related to Enteral Feedings Risk for Impaired Skin Integrity Related to the Presence of NG Tube Risk for Unstable Blood Glucose Related to Enteral Feedings Risk for Impaired Verbal Communication Related to Presence of NG Tube

Risk for Impaired Skin Integrity Related to the Presence of NG Tube Explanation: NG tubes can easily damage the delicate mucosa of the nose, sinuses, and upper airway. An NG tube does not preclude verbal communication. This client's NG tube is in place for decompression, so complications of enteral feeding do not apply.

The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client? A complete blood count including differential Serum antibodies for H. pylori A sigmoidoscopy Gastric analysis

Serum antibodies for H. pylori Explanation: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? Sialolithiasis Parotitis Sialadenitis Stomatitis

Sialolithiasis Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected? Liver Ileum Stomach Large Intestine

Stomach Explanation: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.

The nurse is preparing to examine the abdomen of a client who reports a change in bowel pattern. The nurse would place the client in which position? Supine with knees flexed Knee-chest Lithotomy Left Sim's lateral

Supine with knees flexed Explanation: When examining the abdomen, the client lies supine with knees flexed. This position assists in relaxing the abdominal muscles. The lithotomy position commonly is used for a female pelvic examination and to examine the rectum. The knee-chest position can be used for a variety of examinations, most commonly the anus and rectum. The left Sim's lateral position may be used to assess the rectum or vagina and to administer an enema.

The client has a chancre on the lips. What instruction should the nurse provide? Apply warm soaks to the lip. Gargle with an antiseptic solution. Avoid foods that could irritate the lesion. Take measures to prevent spreading the lesion to other people.

Take measures to prevent spreading the lesion to other people. Explanation: A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.

What would the nurse recognize as preventing a client from being able to take a fecal occult blood test (FOBT)? The client has hemorrhoidal bleeding The client had a hamburger for dinner the night before The client took an ibuprofen tablet this morning The client regularly takes aspirin

The client has hemorrhoidal bleeding Explanation: FOBT should not be performed when there is hemorrhoidal bleeding. In the past, clients were taught to avoid aspirin, red meats, nonsteroidal anti-inflammatory agents, and horseradish for 72 hours prior to the examination. However, these restrictions are no longer advised as the actual effects on testing have not been established.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client doesn't exhibit rectal tenesmus. The client is free from esophagitis and achalasia. The client reports diminished duodenal inflammation. The client has normal gastric structures.

The client is free from esophagitis and achalasia. Explanation: Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for recent foods ingested. occult blood. ingestion of bismuth. pilonidal cyst.

recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. Ingestion of bismuth can turn the stool black and, when occult blood is present, the stool can appear to be tarry black.

After teaching nursing students about methods to assess gastric tube placement, the instructor determines that the teaching was successful when the group identifies which of the following as the most accurate method? X-ray visualization Measurement of exposed tubing pH measurement of aspirate Air auscultation

X-ray visualization Explanation: X-ray visualization of the tube tip is the most accurate method to verify placement; however, it is also the most expensive method and exposes the patient to radiation doses. Measuring the length of the exposed tubing only provides information about the position, not the location, of the tip. Testing the pH of the aspirate helps to distinguish between gastric and intestinal placement. This method also can be affected by interventions such as the use of antacids or continuous tube feedings. Air auscultation is highly variable, and normal bowel and bronchial sounds may interfere with interpretation.

Which nursing instruction is correct to provide the client following a barium enema? The client will maintain a low residue diet. The stools may be a white or clay colored. Sips of fluid may be increased if tolerated. An enema will be used to clear the bowel.

The stools may be a white or clay colored. Explanation: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.

A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor? Both tests need to be done before breakfast. The ultrasonography should be scheduled before the GI procedure. The upper GI should be scheduled before the ultrasonography. The client may eat a light meal before either test.

The ultrasonography should be scheduled before the GI procedure. Explanation: Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.

The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure? The client is probably hypoglycemic and requires the glucagon. To relieve anxiety during the procedure for moderate sedation. To reduce air accumulation in the colon. To relax colonic musculature and reduce spasm.

To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.

Which of the following is the most common type of diverticulum? Zenker's diverticulum Mid-esophageal Epiphrenic Intramural

Zenker's diverticulum Explanation: The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

The nurse is inserting a nasoenteric tube for a patient with a paralytic ileus. How long does the nurse anticipate the tube will be required? (Select all that apply.) Until bowel sound is present Until flatus is passed Until peristalsis is resumed Until the patient stops vomiting Until the tube comes out on its own

Until bowel sound is present Until flatus is passed Until peristalsis is resumed Before removing an enteral tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the primary provider. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.

A client receives tube feedings. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration? Change the tube feeding container ,tubing, and adjust patient head of bed Avoid cessation of feedings and adjust patient head of bed. Use semi-Fowler position during, and 60 minutes after, an intermittent feeding Administer 15 to 30 mL of water before and after medications and feedings.

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding. Explanation: To minimize the risk of aspiration, it is important to place the client in a semi-Fowler position during, and 60 minutes after, an intermittent feeding because proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting. If aspiration is suspected, feeding should be stopped as cessation prevents further problems and allows for treatment of the immediate problem. Changing tube feeding container and tubing, monitoring weight daily, and administering 15 to 30 mL of water before and after medications and feedings are measures to maintain tube function.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery? Vagus Hypoglossal Vestibulocochlear Trigeminal

Vagus Explanation: Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

The nurse checks residual content before each intermittent tube feeding. When should the patient be reassessed? When the residual is about 50 mL When the residual is between 50 and 80 mL When the residual is about 100 mL When the residual is greater than 200 mL

When the residual is greater than 200 mL Explanation: Although a residual volume of 200 mL or greater is generally considered a cause for concern in patients at high risk for aspiration, feedings do not necessarily need to be withheld in all patients.

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported? chronic atrophic gastritis duodenal ulcer gastric cancer pernicious anemia

duodenal ulcer Explanation: Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.

The nurse determines one or two bowel sounds in 2 minutes should be documented as normal. hyperactive. hypoactive. absent.

hypoactive. Explanation: Hypoactive bowel sound is the description given to auscultation of one to two bowel sounds in 2 minutes. Normal bowel sounds are heard every 5 to 20 seconds. Hyperactive bowel sounds occur when 5 or 6 sounds are heard in less than 30 seconds. The nurse records that bowel sounds are absent when no sound is heard in 3 to 5 minutes.

The nurse prepares to administer the lavage solution to a client having a colonoscopy completed. The nurse stops and notifies the physician when noting that the client has which condition? inflammatory bowel disease chronic obstructive pulmonary disease congestive heart failure pulmonary hypertension

inflammatory bowel disease Explanation: The nurse stops administering the lavage solution and notifies the physician when the nurse notes that the client has inflammatory bowel disease. Another contraindication for use of lavage solution is intestinal obstruction. Chronic obstructive pulmonary disease (COPD), congestive heart failure, and pulmonary hypertension are not contraindications to administration of lavage solution in preparation for a colonoscopy.

The nurse performs an abdominal assessment. The nurse should perform the assessment in which order? inspection, palpation, percussion, auscultation inspection, auscultation, percussion, palpation auscultation, percussion, inspection, palpation auscultation, inspection, percussion, palpitation

inspection, auscultation, percussion, palpation Explanation: The correct order for the abdominal assessment is inspection, auscultation, percussion, and palpation.

The nurse provides health teaching to inform the client with oral cancer that most oral cancers are painful at the outset. blood testing is used to diagnose oral cancer. a typical lesion is soft and craterlike. many oral cancers produce no symptoms in the early stages.

many oral cancers produce no symptoms in the early stages. Explanation: The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.

The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route? nasogastric intubation orogastric intubation nasoenteric intubation gastrostomy

nasogastric intubation Explanation: The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.

Which procedure is performed to examine and visualize the lumen of the small bowel? small bowel enteroscopy colonoscopy panendoscopy peritoneoscopy

small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented? upper GI enteroclysis abdominal ultrasound magnetic resonance imaging positron emission tomography

upper GI enteroclysis Explanation: Enteroclysis is a double contrast study where a duodenal tube is inserted and 500 to 1000 mL of thin barium sulfate suspension and then methylcellulose is infused. Fluoroscopy is used to visualize the filling of the intestinal loops over a period of up to 6 hours. The test is used for detection of small bowel obstruction and diverticuli. Abdominal ultrasound, magnetic resonance imaging, and positron emission tomography do not involve insertion of a duodenal tube.

The nurse recognizes which change of the gastrointestinal system is an age-related change? increased motility hypertrophy of the small intestine weakened gag reflex increased mucus secretion

weakened gag reflex Explanation: A weakened gag reflex is an age-related change of the GI system. There is decreased motility, atrophy of the small intestine, and decreased mucus secretion.