Upper Gastrointestinal Problems
A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.
ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent Helicobacter pylori infection.
An older patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place. The health care provider prescribes 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.
ANS: B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.
Which finding in the mouth of a patient who uses smokeless tobacco is suggestive of oral cancer? a. Bleeding during tooth brushing b. Painful blisters at the lip border c. Red, velvety patches on the buccal mucosa d. White, curdlike plaques on the posterior tongue
ANS: C A red, velvety patch suggests erythroplasia, which has a high incidence (>50%) of progression to squamous cell carcinoma. The other lesions are suggestive of acute processes (e.g., gingivitis, oral candidiasis, herpes simplex).
A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring? A. Malnutrition B. Bile reflux gastritis C. Dumping syndrome D. Postprandial hypoglycemia
C. Dumping syndrome After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating. Awarded 0.0 points out of 1.0 possible points.
The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit? A. Turn, deep breathe, cough, and use spirometer every 4 hours. B. Maintain an upright position for at least 2 hours after eating. C. NG will have bloody drainage and it should not be repositioned. D. Keep in a supine position to prevent movement of the anastomosis.
C. NG will have bloody drainage and it should not be repositioned. The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler's or Fowler's position, not supine, to prevent reflux and aspiration of secretions.
Vasopressin 0.1 unit/min infusion is prescribed for a patient with acute arterial gastrointestinal (GI) bleeding. The vasopressin label states vasopressin 100 units/250 mL normal saline. How many mL/hr will the nurse infuse?
ANS: 15 There are 0.4 unit/1 mL. An infusion of 15 mL/hr will result in the patient receiving 0.1 units/min as prescribed.
The family member of a patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. prevent aspiration of gastric contents. b. inhibit the development of stress ulcers. c. lower the chance for H. pylori infection. d. decrease the risk for nausea and vomiting.
ANS: B Famotidine is administered to prevent the development of physiologic stress ulcers, which are associated with a major physiologic insult such as massive trauma. Famotidine does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.
The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.
ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.
A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient? A. Barium swallow B. Endoscopic biopsy C. Capsule endoscopy D. Endoscopic ultrasonography
B. Endoscopic biopsy Because of this patient's history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer.
A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement? A. Weight gain of 1 kg in 1 week B. Administer tube feeding at 25 mL/hr. C. Consume 50% of clear liquid tray this shift. D. Monitor for tube for placement and gastrointestinal residual.
A. Weight gain of 1 kg in 1 week The goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. Administering feedings, monitoring tube placement, and tolerance are interventions used to achieve the goal.
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Hemoglobin (Hgb) 10.8 g/dL b. Temperature 102.1°F (38.9°C) c. Absent bowel sounds in all quadrants d. Scant nasogastric (NG) tube drainage
ANS: B An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery and do not require any urgent action.
Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth
ANS: B Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the excess gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."
ANS: B Ranitidine is a histamine-2 (H2) receptor blocker that decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).
A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.
ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.
Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1 L of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.
ANS: C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly, but are not the highest priorities.
A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea? a. Keep the patient NPO for 2 hours before dressing changes. b. Give the ordered prochlorperazine before dressing changes. c. Administer the prescribed morphine sulfate before dressing changes. d. Avoid performing dressing changes close to the patient's mealtimes.
ANS: C Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain. However, an antiemetic may be added later if the nausea persists despite pain management.
A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for a. hydrogen peroxide rinses. b. the use of antiviral agents. c. administration of nystatin tablets. d. referral to a dentist for professional tooth cleaning.
ANS: C Candida albicans infections are treated with an antifungal such as nystatin. Peroxide rinses would be painful. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.
Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective? a. "I will drink more liquids with my meals." b. "I should choose high carbohydrate foods." c. "Vitamin supplements may prevent anemia." d. "Persistent heartburn is common after surgery."
ANS: C Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery, and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.
Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich
ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.
At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.
ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.
After change-of-shift report, which patient should the nurse assess first? a. A 42-yr-old patient who has acute gastritis and ongoing epigastric pain b. A 70-yr-old patient with a hiatal hernia who experiences frequent heartburn c. A 60-yr-old patient with nausea and vomiting who has dry mucosa and lethargy d. 53-yr-old patient who has dumping syndrome after a recent partial gastrectomy
ANS: C This patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.
When a patient is diagnosed with achalasia, the nurse will teach the patient that a. lying down after meals is recommended. b. a liquid or blenderized diet will be necessary. c. drinking fluids with meals should be avoided. d. treatment may include endoscopic procedures.
ANS: D Endoscopic and laparoscopic procedures are the most effective therapy for improving symptoms caused by achalasia. Keeping the head elevated after eating will improve esophageal emptying. A semisoft diet is recommended to improve esophageal emptying. Patients are advised to drink fluid with meals.
An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Aluminum hydroxide c. Omeprazole (Prilosec) d. Metoclopramide (Reglan)
ANS: D Metoclopramide can cause central nervous system side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton pump inhibitors, mucosal protectants, or antacids.
A patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.
ANS: D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating rheumatoid arthritis.
A patient who recently has been experiencing frequent heartburn is seen in the clinic. The nurse will anticipate teaching the patient about a. barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.
ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.
All of the following orders are received for a patient who has vomited 1500 mL of bright red blood. Which order will the nurse implement first? a. Insert a nasogastric (NG) tube and connect to suction. b. Administer intravenous (IV) famotidine (Pepcid) 40 mg. c. Draw blood for typing and crossmatching. d. Infuse 1000 mL of lactated Ringer's solution.
ANS: D Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.
The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I eat small meals throughout the day and have a bedtime snack."
ANS: D GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.
Which patient would be at highest risk for developing oral candidiasis? A. A 74-yr-old patient who has vitamin B and C deficiencies B. A 22-yr-old patient who smokes 2 packs of cigarettes per day C. A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks D. A 58-yr-old patient who is receiving amphotericin B for 2 days
C. A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent's infection. Use of tobacco products leads to stomatitis, not candidiasis.
The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection? A. "Eating raw cookie dough from the package is a great snack when you do not have time to bake." B. "Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time." C. "To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers." D. "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate."
D. "When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate." The student who did not accept the pink hamburger and asked for a new bun and clean plate understood that the pink meat may not have reached 160°F and could be contaminated with bacteria. Improperly storing cooked foods, eating raw cookie dough from a refrigerated package, and only using one cutting board without washing it with hot soapy water between the chicken and salad vegetables could all lead to food poisoning from contamination.
