MedSurg Adult Heath GI
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) after extensive colon surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client states, "TPN: 1. Provides short-term nutrition after surgery." 2. Assists in providing supplemental nutrition." 3. Provides total nutrition when gastrointestinal (GI) function is questionable." 4. Assists people who are unable to eat but have active GI function."
3 When GI absorption is inadequate, TPN is the nutritional therapy of choice because it provides needed nutrients. TPN usually is used with chronic or long-term therapy, not for short-term therapy. TPN is used for total, not supplemental, nutrition. The response "assists people who are unable to eat but have active GI function" is not the indication for TPN; a feeding tube would be used in this instance.
A client has a transverse loop colostomy. What should the nurse do when inserting a catheter for the colostomy irrigation? 1. Use an oil-based lubricant. 2. Instruct the client to bear down. 3. Apply gentle but continuous pressure. 4. Direct it toward the client's right side.
4 A transverse colostomy is an opening created in the transverse colon. The rectal tube should be pointed to the proximal intestine, which contains the feces. A water-soluble lubricant should be used to facilitate insertion. There are no sphincters, so bearing down is unnecessary. Continual pressure may traumatize the mucosa; lack of nerve endings diminishes sensation.
When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client states that the preferred breakfast cereal is: 1.Froot Loops 2. Corn Flakes 3. Cap'n Crunch 4. Shredded Wheat
4 Shredded Wheat contains 5.5 grams of fiber per serving, which is more than the other choices. Froot Loops contain 0.8 gram of fiber per serving. Corn Flakes contain 0.7 gram of fiber per serving. Cap'n Crunch contains 0.7 gram of fiber per serving.
A health care provider prescribes daily docusate sodium (Colace) for a client. The nurse determines that the action of this drug in the gastrointestinal (GI) tract is to: 1. Lubricate the feces. 2. Create an osmotic effect. 3. Stimulate motor activity. 4. Lower the surface tension of feces.
4 The detergent action of docusate sodium promotes the drawing of fluid into the stool, which softens the feces. Lubricating the feces in the GI tract is the action of lubricant laxatives such as mineral oil. Creating an osmotic effect in the GI tract is the action of saline laxatives, such as magnesium hydroxide (Milk of Magnesia). Stimulating motor activity of the GI tract is the action of peristaltic stimulants, such as cascara.
A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client? 1. Provide frequent saline mouthwashes. 2. Use karaya powder to decrease irritation. 3. Increase fluid intake to compensate for accompanying diarrhea. 4. Provide meticulous skin care of the abdomen with an antiseptic.
1 Saline mouthwashes are soothing to the oral mucosa and help clean the mouth, minimizing infection. Stomatitis refers to the oral cavity; karaya is used to protect the skin around a stoma created on the abdomen. Stomatitis does not cause diarrhea or fluid loss. The abdomen is not involved; stomatitis is an inflammation of the oral mucosa.
The nurse is caring for a client with cancer of the rectum that is scheduled for an abdominoperineal resection with the creation of a colostomy. The client will sign a consent form for a: 1. Permanent sigmoid colostomy. 2. Permanent ascending colostomy. 3. Temporary double-barrel colostomy. 4. Temporary transverse loop colostomy.
1 When intestinal continuity cannot be restored after removal of the anus, rectum, and adjacent colon, a permanent colostomy is formed. The ascending segment of the colon lies on the right side of the abdomen and has no anatomical proximity to the rectum. Temporary double-barrel colostomy is performed to allow a segment of colon to heal; intestinal continuity is restored eventually. Temporary transverse loop colostomy commonly is performed for inflammation of the colon when intestinal continuity eventually can be restored.
A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. The nurse explains that a PEG tube is preferred for administering a tube feeding because: 1. There is less chance of aspiration 2. This procedure does not require a pump 3. Self-administration of the feeding is possible 4. More tube feeding mixture can be given each time
1 When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.
A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit? Select all that apply. 1. Fever 2. Hyperactivity 3. Extreme hunger 4. Urinary retention 5. Abdominal muscle rigidity
1, 5 A moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity, is often associated with peritonitis. Nausea, not hunger, is a common occurrence with peritonitis. Urinary retention may occur following surgery as a complication of anesthesia, not peritonitis.
An 85-year-old client has a three-day history of nausea, vomiting, and diarrhea. The client develops weakness and confusion and is admitted to the hospital. To best monitor the client's rehydration status, the nurse should assess the client's: 1. Skin turgor 2. Daily weight 3. Urinary output 4. Mucous membranes
2 A continuous increase in serial weight determinations indicates a movement toward correction in the dehydration; 1 L of fluid weighs 2.2 pounds. The skin in older adults has less fluid and subcutaneous fat than younger adults, which results in a subjective and inaccurate assessment of rehydration. In older adults there can be a 50% decrease in renal blood flow and tubular function; therefore, urinary output does not provide an accurate assessment of rehydration therapy. The mucous membranes in older adults are drier than in younger adults because of the decrease in salivary secretions and therefore do not provide an accurate assessment of rehydration therapy.
When reviewing an appropriate diet for a client with diabetes, the client expresses a dislike for sweet potatoes. What should the nurse suggest is a safe equivalent for sweet potatoes? 1. Cup of milk 2. White bread 3. Slice of avocado 4. Mayonnaise on salad
2 A sweet potato is equivalent to a serving of bread. One cup of skim or nonfat milk is a serving of milk. A slice of avocado is equivalent to a serving of fat. One teaspoon of mayonnaise is equivalent to a serving of fat.
A nurse is reviewing a newly admitted client's medication administration record (MAR). The nurse identifies that it is incomplete when the record is lacking information regarding the client's: 1. Height 2. Allergies 3. Body weight 4. Medical diagnosis
2 Allergies should be listed on all MARs to prevent the administration of drugs to which the client is allergic. Height is part of the initial health history/physical assessment data. Weight is part of the initial health history/physical assessment data. The medical diagnosis is part of the initial health history/physical assessment data.
Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel? 1. Apply insect repellent. 2. Drink only bottled water. 3. Avoid drinking pasteurized milk. 4. Obtain vaccine prior to foreign travel.
2 Entamoeba histolytica, the organism that causes amebic dysentery, is transmitted through excreta; bottled water prevents consumption of water that may be contaminated by the causative microorganism. Amebic dysentery is not a mosquito- or tick-borne disease. Pasteurization kills microorganisms that can cause disease. Vaccines do not prevent amebic dysentery.
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. 1. High protein diet 2. Low sodium diet 3. Daily abdominal girth measurements 4. Encourage increased by mouth fluid intake 5. Daily weights
2, 3, 5 In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms and often these clients are on a fluid restriction
For which complication should the nurse assess a client who had a bilateral herniorrhaphy? 1. Hydrocele 2. Paralytic ileus 3. Urinary retention 4. Thrombophlebitis
3 Because of pain and the proximity of the operative site to the lower urinary tract, voiding problems are common. Hydrocele is not a complication of herniorrhaphy. The abdomen was not entered, and interference with peristalsis should not occur. Thrombophlebitis should not be a complication of herniorrhaphy because early ambulation is encouraged.
Following surgery, a client asks the nurse to help measure intake and output. What is the best nursing response? 1. Determine the client's willingness to really help 2. Identify the client's reason for wanting to do this task 3. Assess the client's ability to measure the intake and output 4. Explain that measuring intake and output is the responsibility of the nurse
3 Clients should be allowed to maintain some control, depending on their ability to perform a given task. The client has indicated willingness by the request. Determining the client's willingness to really help is immaterial. Able clients should be supported to perform self-care.
A client with cancer of the stomach is admitted to the hospital and scheduled for a subtotal gastrectomy. The nurse is providing preoperative teaching. What should the nurse teach the client to do postoperatively to minimize the complication of dumping syndrome? 1. Ambulate after every meal. 2. Remain on a diet low in fat. 3. Eat in a semirecumbent position. 4. Increase fluid intake when eating food.
3 Eating in a semirecumbent position slows gastric emptying, thereby helping to prevent premature passage of gastric contents into the duodenum. Ambulating after meals speeds gastric emptying and should be avoided. A diet low in fat speeds gastric emptying and should be avoided. Increasing fluid intake when eating food speeds gastric emptying and should be avoided.
A client with hepatic cirrhosis develops hepatic encephalopathy. Neomycin sulfate (Mycifradin) is prescribed. The nurse concludes that the purpose of neomycin is to: 1. Decrease intestinal edema 2. Reduce abdominal distention 3. Diminish the blood ammonia level 4. Limit development of systemic infections
3 Neomycin sulfate reduces bacterial activity on blood and wastes in the gastrointestinal (GI) tract, thereby reducing the level of blood ammonia, a byproduct of protein metabolism; hepatic encephalopathy is a result of elevated ammonia levels in the blood. Neomycin sulfate interferes with bacterial protein synthesis but has little or no effect on intestinal edema. Neomycin sulfate reduces bacterial action in the GI tract but does not reduce abdominal distention. Neomycin sulfate does not limit the development of a systemic infection when it is ingested because it is not absorbed systemically.
An 18-year-old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1. Urinary retention 2. Gastric hyperacidity 3. Rebound tenderness 4. Increased lower bowel motility
3 Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.
A client with cirrhosis of the liver and ascites fails to respond to chlorothiazide (Diuril), a thiazide diuretic. Spironolactone (Aldactone) is prescribed in addition to the chlorothiazide. What should the nurse explain to the client about why spironolactone was added to the medication regimen? 1. Promotes water excretion 2. Stimulates sodium excretion 3. Helps prevent potassium loss 4. Reduces arterial blood pressure
3 Spironolactone is a potassium-sparing diuretic often used in conjunction with thiazide diuretics. Both diuretics promote water excretion, so this is not a particular advantage of spironolactone. Both diuretics stimulate sodium excretion, so this is not a particular advantage of spironolactone. Both diuretics reduce arterial blood pressure, so this is not a particular advantage of spironolactone.
A health care provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? 1. Maintaining a supine position during the procedure 2. Consuming a diet low in fat for three days before the procedure 3. Emptying the bladder immediately before the procedure 4. Staying on a liquid diet for 24 hours after the procedure
3 The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.
A client who had previously signed a consent form for a liver biopsy reconsiders and decides not to have the procedure. What is the nurse's best initial response? 1. "Why did you sign the consent form originally?" 2. "I can understand why you changed your mind." 3. "Can you tell me your reasons for refusing the procedure?" 4. "You must be afraid about something concerning the procedure."
3 The response "Can you tell me your reasons for refusing the procedure?" attempts to explore why the client is refusing the procedure and promotes communication. The response "Why did you sign the consent form originally?" is accusatory; the client has the right to withdraw consent at any time. The response "I can understand why you changed your mind" is a conclusion without appropriate data; it may also increase the client's anxiety level. "You must be afraid about something concerning the procedure" is a conclusion without appropriate data; it also puts the client on the defensive.
A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply. 1. Corn 2. Cheese 3. Oatmeal 4. Rye bread 5. Fruit juice
3, 4 Gluten is found in rye, oats, wheat, and barley, which should be avoided because gluten in these grains is irritating to the gastrointestinal mucosa. Gluten is found in oatmeal and rye bread and should be avoided. Gluten is not found in corn. Gluten is not found in milk and dairy products. Gluten is not found in fruit.
A client who is having presurgical testing before a colon resection and possible colostomy says to the nurse, "If I have to have this surgery, I know my partner will never come near me." The nurse's best initial response is "You: 1. Seem concerned that your partner will reject you." 2. Are wondering about the effect on your sexual relations." 3. Are probably underestimating your partner's love for you." 4. Seem worried that the surgery will change how others see you."
4 "You seem worried that the surgery will change how others see you" is an open-ended response that encourages further discussion. The response "You seem concerned that your partner will reject you" is too specific; the nurse does not have enough information to come to this conclusion. The response "You are wondering about the effect on your sexual relations" is too specific; the nurse does not have enough information to come to this conclusion. The response "You are probably underestimating your partner's love for you" denies the client's concern and may cause feelings of guilt for questioning the partner's love.
An emergency department nurse assesses an older client who reports cramping pain in the left lower quadrant, weakness, bloating, and malaise. The client also has a low-grade fever. Which condition does the nurse suspect as the most likely cause of the client's clinical findings? 1. Pancreatitis 2. Appendicitis 3. Cholecystitis 4. Diverticulitis
4 Although diverticula can occur at any point within the gastrointestinal tract, they are most common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the left lower quadrant. Pancreatitis is associated with acute epigastric or left upper quadrant pain. Appendicitis is associated with shifting of periumbilical pain to the lower right quadrant and localizing at McBurney's point. Cholecystitis is associated with right upper quadrant pain that may be referred to the right shoulder and scapula.
A client develops a gallstone that becomes lodged in the common bile duct. An endoscopic sphincterotomy is scheduled. The client asks the nurse what will be done to prevent pain. What should the nurse reply? 1. "All you'll need is an oral painkiller." 2. "Epidural anesthesia usually is given." 3. "You will get a local injection at the site." 4. "An intravenous sedative usually is administered."
4 An intravenous sedative usually is administered to produce effective sedation (conscious sedation) for the procedure. An oral analgesic is insufficient for this procedure. Epidural anesthesia is not necessary. A local anesthetic is insufficient for this procedure.
Which statement made by the client indicates correct understanding of gastroesophageal reflux disease (GERD) management? 1. "I can reduce my GERD symptoms through a high carbohydrate, low fat diet." 2. "A snack at bedtime will help reduce the acidity of my stomach during the night." 3. "Three meals per day is the best regimen to avoid GERD symptoms." 4. "I will place a 6-inch block under the head of my bed to help with digestion."
4 Elevation of the head of the bed can enhance esophageal emptying and reduce symptoms of GERD. A low fat, high protein diet is recommended. Eating should be avoided three hours before bedtime to reduce acid production and the client should be instructed to consume small, frequent meals throughout the day to maintain a steady level of acid production and avoid gastric distention.
A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? 1. Incisional pain 2. Wound dehiscence 3. Anastomosis leakage 4. Pulmonary embolism
4 Immobility contributes to venous stasis, which can cause deep vein thrombosis and pulmonary embolism. Insufficient mobility does not contribute to incisional pain; incisional pain contributes to immobility. Stressors commonly associated with wound dehiscence include obesity, infection, and poor wound healing, not immobility. Anastomosis leakage occurs when gastrointestinal contents leak into the abdominal cavity; it is caused by leakage around or separation of sutures or staples where the stomach is stapled or the loop of jejunum is anastomosed to a new outlet from the stomach, or where it is attached to the proximal jejunum.
During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first: 1. Suggest that an antiemetic be prescribed 2. Change the feeding schedule to omit nights 3. Request that the type of solution be changed 4. Gather more data from the night nurse about the technique used
4 Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first.
A nurse administers sodium polystyrene sulfonate (Kayexalate) to a client. What should the nurse monitor to evaluate the effectiveness of the Kayexalate? 1. Urinary output 2. Blood pressure 3. Bowel function 4. Serum potassium
4 Serum potassium resin exchanges sodium ions for potassium in the large intestine to lower serum potassium. Urinary output is not affected directly by this drug. Blood pressure is not affected directly by this drug. Although constipation and diarrhea are both adverse effects of this drug, they do not supply evidence of its therapeutic effect.
A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client: 1. Clamps off the flow of fluid when feeling uncomfortable 2. Lubricates the tip of the catheter before inserting it into the stoma 3. Discontinues the insertion of fluid after only a half a liter of fluid is instilled 4. Hangs the irrigation bag on the door clothes hook during fluid insertion
4 The irrigation bag should be hung no higher than 12 to 18 inches above the level of the stoma; a clothes hook is too high. Fluid flowing into the intestines can cause distention and discomfort; clamping the tubing is an appropriate intervention. The tip of the catheter should be lubricated to prevent trauma to mucosal tissue and to facilitate insertion. Discontinuing the irrigation after a half a liter of fluid is instilled is not inappropriate; 500 to 1000 mL of water is used when performing a colostomy irrigation.
What should the nurse include in the discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home? 1. Listing the schedule of the days the client is receive the TPN 2. Changing the TPN access device daily 3. Contacting and scheduling professionals to administer the TPN 4. Administering the TPN while working around the client's normal activities
4 The less disruptive the procedure, the greater the acceptance by the client. Most often, total parenteral nutrition is set up to run daily during sleeping hours. Depending on the type of circulatory access used, it may not need to be changed for weeks. The client or a significant other can be taught the principles of administration.
A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain most likely will remain contaminated with the hepatitis A virus after being cooked? 1. Canned tuna 2. Broiled shrimp 3. Baked haddock 4. Steamed lobster
4 The temperature during steaming is never high enough or sustained long enough to kill microorganisms. Processing destroys the virus. Because of the extremely high temperature, broiling sufficiently destroys the virus. Baking will destroy the virus.
For two months a client has been taking nonprescription medications and has made dietary changes for symptoms of gastritis. Following assessment by a primary health care provider, a diagnosis of extensive carcinoma of the stomach is made. The client asks how the disease got so advanced. The nurse's explanation is based on the knowledge that carcinoma of the stomach: 1. Presents symptoms of severe pain for the client when in the early stages of the disease process. 2. Is a risk factor for clients that had bariatric surgery in the past five years. 3. Usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area. 4. Often is diagnosed late because symptoms are nonspecific during the early stages.
4 This cancer usually is asymptomatic in the early stages; the stomach accommodates the mass. Gastric cancer is painless in its early stages. There is an increased risk of developing stomach cancer starting at about 15 years after having had stomach surgery. Gastric washings or biopsy can accurately diagnose it. Hodgkin's disease usually is diagnosed after the discovery of enlarged lymph nodes in the epigastric area, not gastric carcinoma.
A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. What is a nursing responsibility common to preparing both of these clients for these procedures? 1. Withholding food for several hours 2. Giving castor oil the afternoon before 3. Administering soapsuds enemas until clear 4. Ensuring an understanding of the procedure
4 To promote understanding and to allay anxiety, all diagnostic tests should be explained to the client. Preparations for tests may vary depending on the client's condition
A client who recently immigrated to the United States has a chronic vitamin A deficiency. What information about vitamin A should the nurse consider when assessing this client for clinical indicators of this deficiency? 1. Vitamin A is an integral part of the retina's pigment called melanin. 2. It is a component of the rods and cones, which control color visualization. 3. Vitamin A is the material in the cornea that prevents the formation of cataracts. 4. It is a necessary element of rhodopsin, which controls responses to light and dark environments.
4 Vitamin A is used in the formation of retinol, a component of the light-sensitive rhodopsin (visual purple) molecule. Melanin is a pigment of the skin. Vitamin A does not influence color vision, which is centered in the cones. The cornea is a transparent part of the anterior portion of the sclera; a cataract is opacity of the usually transparent crystalline lens. Vitamin A does not prevent cataracts.
