NUR 212 Chap 52
When performing an assessment, the nurse detects a fruity odor on the client's breath. What does the nurse do next? a. Assess the client's blood sugar level. b.Assess the client's stool for occult blood. c.Instruct the client in oral hygiene techniques. d.Assess the client for petechiae, itching, and jaundice.
ANS: A A fruity odor to the breath may indicate uncontrolled or undiagnosed diabetes mellitus. The client's blood sugar level should be checked immediately for hyperglycemia. The nurse may perform the other assessment tests for the client, but they will not be helpful in determining the cause of the fruity breath.
Which question best assists the nurse in assessing a client with acute diarrhea? a. "Have you traveled outside the country recently?" b. "Have you had a colonoscopy lately?" c. "Do you have any trouble swallowing?" d. "Do you have any allergies?"
ANS: A A history of recent travel may help pinpoint an infectious source for the client's diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.
The nurse is preparing the client for a computed tomography (CT) scan of the abdomen with IV contrast. Which question does the nurse ask the client before the examination? a. "Are you allergic to shrimp, scallops, or shellfish?" b. "Have you had anything to eat or drink in the past 12 hours?" c. "Did you finish taking all the prescribed laxatives?" d. "Can you tolerate being tilted from side to side?"
ANS: A Allergies to iodine or seafood can cause a cross-allergic reaction to the contrast dye used for CT scans. Clients reporting such allergies should be scheduled for CT without contrast to avoid anaphylactic reactions. The client does not need to be NPO for this test and does need not to take laxatives. The client is not tilted during the CT scan.
An older client has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." b. "Perhaps you don't need as high a dose of the drug as before." c. "Stomach muscles atrophy with age and you digest more slowly." d. "Your body probably can't tolerate as much medication anymore."
ANS: A Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugs—possibly to toxic levels. The other options do not accurately explain this age-related change.
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching? a. "It's a good thing I love orange and cherry gelatin." b. "My spouse will be here to drive me home." c. "I should refrigerate the GoLYTELY before use." d. "I will buy a case of Gatorade before the prep."
ANS: A The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.) a. Colon cancer b. Diverticulitis c. Inflammatory bowel disease d. Peptic ulcer disease e. Pernicious anemia
ANS: A, B, C, D In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.) a. Cholangitis b. Pancreatitis c. Perforation d. Renal lithiasis e. Sepsis
ANS: A, B, C, E Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) a. Decreased hydrochloric acid production b. Diminished sensation that can lead to constipation c. Fat not digested as well in older adults d. Increased peristalsis in the large intestine e. Pancreatic vessels become calcified
ANS: A, B, C, E Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels.
The nurse is aware of the 2014 American Cancer Society Screening Guidelines for colon cancer, which include which testing modalities for people over the age of 50? (Select all that apply.) a. Colonoscopy every 10 years b. Colonoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 10 years
ANS: A, C The options for colon cancer screening for people over the age of 50 include colonoscopy every 10 years and CT colonography, double-contrast barium enema, or flexible sigmoidoscopy every 5 years.
The student nurse studying the gastrointestinal system understands that chyme refers to what? a. Hormones that reduce gastric acidity b. Liquefied food ready for digestion c. Nutrients after being absorbed d. Secretions that help digest food
ANS: B Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys b. Liver c. Spleen d. Stomach
ANS: B Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting proteins. The other organs are not related to this issue.
17. The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? a. Keep the client NPO (nothing by mouth). b. Check the client's gag reflex. c. Offer the client sips of clear liquids. d. Provide the client with a few ice chips.
ANS: B The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned.
The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to what organ dysfunctions? (Select all that apply.) a. Alanine aminotransferase: biliary system b. Ammonia: liver c. Amylase: liver d. Lipase: pancreas e. Urine urobilinogen: stomach
ANS: B, D Alanine aminotransferase and ammonia are related to the liver. Amylase and lipase are related to the pancreas. Urobilinogen evaluates both hepatic and biliary function.
The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds. Which is the nurse's best action? a. Notify the health care provider. b. Percuss the abdomen. c. Document the finding. d. Insert a nasogastric tube.
ANS: C Absent bowel sounds are expected immediately following abdominal surgery. The finding should be noted in the client's record for later reference. The provider does not need to be notified at this time. The nurse should insert a nasogastric tube if ordered by the physician if the ileus persists. Percussion may be performed but may be uncomfortable for the client and will not reveal the cause of the ileus.
A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best? a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.
ANS: C After a colonoscopy with biopsy, a small amount of bleeding is normal. The nurse should remind the client of this and instruct him or her to go to the emergency department for large amounts of bleeding, severe pain, or dizziness.
The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure? a. "I may have gas and abdominal cramps after the test." b. "I will take strong laxatives the afternoon before the test." c. "I will take my Coumadin with a sip of water tomorrow morning." d. "I will take nothing by mouth after midnight on the day of the test."
ANS: C Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.
1. The nurse is caring for a client who is receiving radiation treatment for oral cancer. Which problem does the nurse anticipate for this client? a. Failure to absorb nutrients from the stomach b. Inability to digest protein c. Impaired ability to soften and break down food d. Difficulty swallowing food
ANS: C Saliva is responsible for the softening of food in the mouth and contains an enzyme, salivary amylase (ptyalin), which assists in the breakdown of carbohydrates. Radiation to the oral cavity can result in reduction of saliva production. Radiation to the mouth will not impair swallowing, ability to digest protein, or ability to absorb nutrients from the stomach.
Which laboratory finding does the nurse expect to find on assessment of a client with advanced cirrhosis? a. Amylase, 129 IU/L; alkaline phosphate, 45 U/L b. Reticulocyte count, 1%; magnesium, 1.5 mEq/L c. Hemoglobin, 14 g/dL; direct bilirubin, 0.2 mg/dL d. Prothrombin time (PT), 17.5 seconds; albumin, 1.6 g/dL
ANS: D Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired. The other laboratory values are within normal limits and would not be expected with advanced cirrhosis.
The nurse is performing an abdominal assessment on an older client. Which assessment finding does the nurse expect as a normal consequence of aging? a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric acid production and heartburn d. Impaired sensation to defecate and constipation
ANS: D Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.
To promote comfort after a colonoscopy, in what position does the nurse place the client? a. Left lateral b. Prone c. Right lateral d. Supine
ANS: A After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.
A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best? a. Ask the client about shellfish allergies. b. Document this information on the chart. c. Ensure that the client has a ride home. d. Instruct the client on bowel preparation.
ANS: A PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.
The nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client? a. "Drink plenty of fluids over the next few days." b. "Do not eat or drink anything for 6 hours after the test." c. "You may not drive or operate heavy machinery today." d. "Do not take any blood thinners for 24 hours after the test."
ANS: A The client is encouraged to drink plenty of fluids after a barium swallow to help eliminate the barium from the colon. Limiting the diet as the barium is being cleared is not necessary. The test will not make the client drowsy, so driving should not be limited. Similarly, blood thinners will not affect the client.
The nurse assesses dullness at the left anterior axillary line. The nurse is concerned about which condition that the client may have? a. Cirrhosis b. Splenomegaly c. Bowel obstruction d. Abdominal aortic aneurysm
ANS: B Dullness in front of the tenth intercostal space, at the left anterior axillary line, is indicative of splenomegaly, which is commonly seen with mononucleosis. Cirrhosis would be noted with percussion in the client's left upper quadrant, indicating hepatomegaly. The nurse may note tympanic sounds with bowel obstruction. Percussion would not be used to assess abdominal aortic aneurysm.
The nurse performs percussion of a client's abdomen. Which findings may the nurse determine with this assessment technique? (Select all that apply.) a. Hepatomegaly b. Kidney stones c. Ascites d. Large mass below the liver e. Biliary colic f. Ileus
ANS: A, C, D, F Percussion allows the nurse to identify the presence of masses, fluid, enlarged organs, and air in the abdomen. The nurse would not be able to identify biliary colic or kidney stones with percussion.
An abdominal ultrasound is scheduled for the client. Which statement by the client indicates that the nurse's teaching about the procedure was effective? a. "The IV contrast may burn when it is injected." b. "I will drive myself home after the test is completed." c. "I will empty my bladder completely before the test." d. "I may have to take a laxative to pass the barium afterward."
ANS: B Because sedation is not used for this test, clients may drive themselves home after the abdominal ultrasound is completed. Barium and IV contrast are not needed. The client's bladder should be full for accurate visualization.
The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer? a. Older white client with irritable bowel syndrome b. Middle-aged African-American client who smokes cigars c. Middle-aged Asian client who travels and eats out frequently d. Older American Indian client taking hormone replacement therapy
ANS: B Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.
A client has been taking naproxen (Naprosyn) for several months. Which assessment question is important for the nurse to ask? a. "Have you experienced any constipation?" b. "Have you had any stomach pain or indigestion?" c. "Have you had any difficulty swallowing?" d. "Have you noticed any weight loss lately?"
ANS: B Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through inhibition of prostaglandins, which normally protects the gastric mucosa. The client should be assessed for stomach pain or indigestion. This medication does not typically cause constipation or difficulty swallowing. Weight loss would not be related to this medication.
A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? a. Allow the client cool liquids only. b. Assess the client's gag reflex. c. Remind the client to remain NPO. d. Tell the client to wait 4 hours.
ANS: B The local anesthetic used during this procedure will depress the client's gag reflex. After the procedure, the nurse should ensure that the gag reflex is intact before offering food or fluids. The client does not need to be restricted to cool beverages only and is not required to wait 4 hours before oral intake is allowed. Telling the client to remain NPO does not inform the client of when he or she can have fluids, nor does it reflect the client's readiness for them.
18. A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer? a. Cholesterol b. Serum lipase c. Carcinoembryonic antigen d. Xylose absorption
ANS: C The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important? a. Ask the client about recent exposure to illness. b. Assess the client's stool for obvious food particles. c. Include the date and time on the specimen container. d. Put on gloves prior to collecting the sample
ANS: D To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.
The nurse finds a positive Blumberg's sign in a client with abdominal pain. Which action does the nurse plan? a. Have the client be NPO in preparation for surgery. b. Document this normal finding in the client's record. c. Immediately auscultate the client's abdomen for bowel sounds. d. Repeat the maneuver with the client in a supine position, with the knees flexed.
ANS: A A positive Blumberg's sign (rebound tenderness), an abnormal sign, is indicative of peritoneal inflammation, which commonly accompanies appendicitis. The client should be made NPO in preparation for surgery to remove the appendix. The maneuver should not be repeated with the client in the supine position. The nurse should perform auscultation before percussion for the abdominal assessment.
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? a. Auscultate for bowel sounds. b. Notify the provider immediately. c. Order an abdominal flat-plate x-ray. d. Palpate the mass and measure its size
ANS: B This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider.
A client has jaundice and ascites. Which laboratory values indicate hepatic disease? (Select all that apply.) a. Albumin, 2.0 g/dL b. Potassium, 3.0 mEq/L c. Alanine aminotransferase (ALT), 45 IU/L d. Aspartate aminotransferase (AST), 45 U/L e. Unconjugated (indirect) bilirubin, 1 mg/dL f. Ammonia, 120 mg/dL
ANS: A, C, D, E, F Decreased albumin and increased ALT, AST, unconjugated bilirubin, and ammonia all indicate hepatic disease. When the liver is damaged, albumin is not produced by the hepatic cells. ALT and AST liver enzymes increase with liver disease. Bilirubin, the primary component of bile, can be measured as direct or indirect and, if elevated, can indicate impaired secretion. Elevated levels of ammonia indicate severe hepatocellular damage. Decreased potassium does not indicate possible liver involvement but can be reduced by vomiting and diarrhea.
A client reports that he has been passing black stools for the last few days. Which findings from the client's health history does the nurse consider as possible causes? (Select all that apply.) a. Cirrhosis b. Cholecystitis c. Hemorrhoids d. Diverticulitis e. Long-term use of NSAIDs f. Use of iron supplements
ANS: A, E, F Cirrhosis may cause black stools when bleeding occurs from esophageal varices. Long-term NSAID use may lead to gastric ulcer development and bleeding. Iron supplements may turn the color of the stool black. Hemorrhoids or diverticulitis would result in stools that are streaked with red. Cholecystitis may result in pale-colored stools if bile flow is obstructed.
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client? a. Colonoscopy b. Enzyme-linked immunosorbent assay (ELISA) toxin A+B c. Ova and parasites d. Stool culture
ANS: B Clients taking antibiotics are at risk for Clostridium difficile infection. The most common test for this disorder is a stool sample for ELISA toxin A+B. Colonoscopy, ova and parasites, and stool culture are not warranted at this time.
The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis. In what sequence does the nurse palpate the client's abdomen? a. Palpate the lower quadrants only. b. Palpate the upper quadrants last. c. Palpate the upper quadrants only. d. Defer palpation and use percussion only.
ANS: B The client with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the client from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. All quadrants should be palpated. Palpation is an important assessment tool that should not be deferred for this client.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client's respiratory rate is 8 breaths/min. What action by the nurse is best? a. Administer naloxone (Narcan). b. Call the Rapid Response Team. c. Provide physical stimulation. d. Ventilate with a bag-valve-mask.
ANS: C For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse's first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
While a health history is obtained from a client with a new diagnosis of advanced pancreatic cancer, the client begins to cry. Which is the nurse's best response? a. "I am so sorry for making you cry!" b. "I will step out for a few minutes until you feel better." c. "I can see that you are upset about this. It is all right to cry." d. "I can see that I am upsetting you. Let's move on to something else."
ANS: C The nurse should recognize the client's feelings and should allow the client to cry. Moving on to another topic shows disregard for the client's feelings. The nurse should not leave the room but should stay to offer support. Apologizing to the client does not place the focus on the client or acknowledge the client's feelings and emotions in this situation.
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this client's abdomen? a. Auscultate after palpating. b. Avoid any palpation. c. Palpate the RUQ first. d. Palpate the RUQ last.
ANS: D If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could possibly affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation.