Free Gastrointestinal Systems practice for ATI Gastrointestinal System (ATI RN). Answer 76 nursing exam-style questions with rationales, exam mode, and progress
In a client with diarrhea, which outcome indicates that fluid resuscitation is successful?
Select the best answer.
Explanation:
Firm skin turgor indicates adequate hydration, which is a key goal of fluid resuscitation. Formed stools, decreased stool frequency, and relief from perianal burning are important but do not directly indicate successful fluid resuscitation.
Which of the following measures should the nurse focus on for the client with esophageal varices?
Select the best answer.
Explanation:
The primary focus for a client with esophageal varices is recognizing hemorrhage because these varices can rupture and cause significant bleeding.
During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?
Select the best answer.
Explanation:
The presence of pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm, which is a serious condition and should be reported to the physician promptly. A concave, midline umbilicus is a normal finding. Bowel sound frequency can vary widely and is not a cause for concern at 15 sounds per minute. Absence of a bruit is a normal finding in an abdominal assessment and does not require reporting.
To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine which body areas?
Select the best answer.
Explanation:
To accurately assess for jaundice in a patient with dark skin pigmentation, the nurse should examine the hard palate of the mouth. Jaundice is best assessed in the sclera; however, in dark-skinned patients, normal yellow pigmentation may be present in the sclera, making it difficult to detect jaundice. Inspection of the hard palate for a yellow color can confirm the presence of jaundice. Cyanosis is best observed in the nail beds, not indicative of jaundice. While skin on the palm of the hand can indicate jaundice, the back of the hand is not a typical area for assessment. Jaundice can be assessed on the soles of the feet in dark-skinned patients, but it is better visualized in the hard palate for accurate evaluation.
The nurse is caring for a client with chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which of the following vitamin deficiencies?
Select the best answer.
Explanation:
Clients with chronic gastritis are at risk for Vitamin B12 deficiency due to impaired absorption.
A client has just had surgery for colon cancer. Which of the following disorders might the client develop?
Select the best answer.
Explanation:
After surgery for colon cancer, the client may develop a partial bowel obstruction.
Jerod is experiencing an acute episode of ulcerative colitis. What is the priority for this patient?
Select the best answer.
Explanation:
The correct answer is to replace lost fluid and sodium. During an acute episode of ulcerative colitis, the priority is to manage the patient's fluid and electrolyte balance. This is crucial due to the potential for dehydration and electrolyte imbalances resulting from diarrhea and inflammation in the colon. Monitoring serum glucose levels (Choice B) may be important for patients on steroid therapy, but in this scenario, fluid and electrolyte balance take precedence. Restricting dietary intake of foods high in potassium (Choice C) is not a priority in the acute phase of ulcerative colitis. While noting changes in stool color and consistency (Choice D) is important for assessing the patient's gastrointestinal status, it is not the priority when managing acute ulcerative colitis.
A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:
Select the best answer.
Explanation:
A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.
The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?
Select the best answer.
Explanation:
Aspiration of gastric contents can lead to a chronic cough in clients with GERD.
Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?
Select the best answer.
Explanation:
A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.
The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. Which of the following would the nurse include in the plan?
Select the best answer.
Explanation:
Bedrest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Coughing is avoided to prevent disruption of the tissue integrity, which can occur because of the location of this surgical procedure.
Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:
Select the best answer.
Explanation:
Diverticulitis is characterized by crampy lower left quadrant pain and a low-grade fever.
A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?
Select the best answer.
Explanation:
Implementing total parenteral nutrition helps meet the nutritional needs of a client with persistent diarrhea and significant weight loss due to ulcerative colitis.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
Select the best answer.
Explanation:
Documenting the findings is the most appropriate action as 750ml of green-brown drainage is expected after a cholecystectomy.
Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication?
Select the best answer.
Explanation:
The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication.
Christina is receiving an enteral feeding that requires a concentration of 80ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?
Select the best answer.
Explanation:
For an 8 oz (240 ml) can of feeding, mix 60 ml of water to achieve the required concentration.
After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:
Select the best answer.
Explanation:
The purpose of the Jackson-Pratt drain is to prevent the accumulation of drainage in the wound after an abdominal resection.
Which of the following terms best describes the pain associated with appendicitis?
Select the best answer.
Explanation:
The correct answer is D: Steady. The pain associated with appendicitis is typically constant and steady, especially in the lower right quadrant of the abdomen. It is not described as aching (choice A) because it is more persistent and severe than a dull ache. It is not fleeting (choice B) as appendicitis pain tends to worsen over time. It is also not intermittent (choice C) as the pain is continuous and does not come and go.
Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?
Select the best answer.
Explanation:
Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction. The client may chew gum if desired. The client may eat chocolate if desired. A client with a peptic ulcer should check with the physician before taking any over-the-counter drug, but acetaminophen does not typically cause gastric irritation.
A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse assesses the client, knowing that which of the following is a hallmark sign of this disorder?
Select the best answer.
Explanation:
A hallmark sign of acute pancreatitis is severe abdominal pain that is not relieved by vomiting. Nausea and vomiting are common presenting symptoms, with vomitus typically consisting of gastric and duodenal contents. Hypothermia is not a hallmark sign of acute pancreatitis. Fever, typically less than 38 degrees centigrade, is more common. Epigastric pain radiating to the neck area is not a characteristic sign of acute pancreatitis. Therefore, choice B is the correct answer.
A client is scheduled for an abdominal perineal resection with permanent colostomy. Which of the following measures would most likely be included in the plan for the client's preoperative preparation?
Select the best answer.
Explanation:
Antibiotics are administered preoperatively to reduce the bacterial count in the colon. The client will be placed on a low residue diet to help cleanse the bowel before surgery but typically is not placed on NPO status until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. Chest tubes would not be expected postoperatively. There is no need to limit the client's activity before surgery.
A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color?
Select the best answer.
Explanation:
During the immediate postoperative period after a partial gastrectomy, gastric secretions are expected to be red.
Which of the following conditions is most likely to directly cause peritonitis?
Select the best answer.
Explanation:
A perforated ulcer is most likely to directly cause peritonitis due to the leakage of gastric contents into the peritoneal cavity.
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?
Select the best answer.
Explanation:
It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered. Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended for regular use as they can lead to colonic dilation. The client should maintain a low-residue, high-calorie, caffeine-free diet.
A client with liver dysfunction has low serum levels of thrombin. The nurse provides care, anticipating that this client is most at risk of
Select the best answer.
Explanation:
Thrombin is produced by the liver and is necessary for normal clotting. When a client with liver dysfunction has low serum levels of thrombin, they are at risk of bleeding due to impaired clotting mechanisms. Dehydration (choice A) is not directly related to low thrombin levels. Malnutrition (choice B) may impact overall health but is not the most immediate concern associated with low thrombin levels. Infection (choice D) is not directly related to the clotting function affected by low thrombin levels.
Which of the following definitions best describes gastritis?
Select the best answer.
Explanation:
The correct answer is C: 'Inflammation of the gastric mucosa.' Gastritis is characterized by inflammation of the stomach lining, specifically the gastric mucosa. This inflammation can be caused by various factors such as infections, medications, alcohol, or autoimmune diseases. Choice A, 'Erosion of the gastric mucosa,' is incorrect because erosion refers to the wearing away of tissue rather than inflammation. Choice B, 'Inflammation of a diverticulum,' is incorrect because gastritis specifically involves inflammation of the stomach lining, not a diverticulum. Choice D, 'Reflux of stomach acid into the esophagus,' describes gastroesophageal reflux disease (GERD), which is different from gastritis.
A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following?
Select the best answer.
Explanation:
Frequent vomiting can lead to metabolic alkalosis with hypokalemia due to the loss of stomach acid and electrolytes.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
Select the best answer.
Explanation:
A realistic goal for this client would be to gain relief from epigastric pain. There is no need for vitamin B12 injections because this client has not had any gastric surgery that would lead to vitamin B12 deficiency. Exercise should be modified, not increased, because it can stimulate further production of gastric acid. It is not possible to eliminate stress from a client's life. Instead, the client should be assisted to develop effective coping and problem-solving strategies as necessary.
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching for this client, the nurse should stress:
Select the best answer.
Explanation:
The correct answer is A: increasing fluid intake to prevent dehydration. An ileostomy typically drains liquid waste, so the client is at risk of fluid loss. By increasing fluid intake, the client can prevent dehydration. It's essential for the client to wear a collection appliance at all times because ileostomy drainage is incontinent. Consuming a low-protein, high-fiber diet is not recommended as high-fiber foods can cause intestinal irritation. Enteric-coated medications should be avoided because they may not be absorbed properly after an ileostomy.
Which of the following tests is most commonly used to diagnose cholecystitis?
Select the best answer.
Explanation:
An abdominal ultrasound is the most commonly used test to diagnose cholecystitis.
A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
Select the best answer.
Explanation:
A Sengstaken-Blakemore tube is inserted into a client with a diagnosis of cirrhosis and ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated the client may begin to bleed again from the esophageal varices, noted by vomiting of blood.
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
Select the best answer.
Explanation:
The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumber, and eggs are gas-forming foods.
Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?
Select the best answer.
Explanation:
Administering pain medication would have the highest priority during the first hour after the client's admission. Pain relief is essential to address the client's immediate discomfort and distress. Completing the admission history, maintaining hydration, and teaching about planned diagnostic tests are important aspects of care but can be addressed after addressing the client's pain and stabilizing their condition.
A nurse is caring for a client who has a new diagnosis of Crohn's disease. Which of the following findings should the nurse expect?
Select the best answer.
Explanation:
Clients with Crohn's disease often experience fatty stools (steatorrhea) due to malabsorption of fats. This occurs because the inflammation caused by Crohn's disease can affect the small intestine, impairing the body's ability to absorb nutrients. Bloody diarrhea is more commonly associated with ulcerative colitis. Weight gain is not a typical symptom of Crohn's disease; instead, weight loss is more common due to malabsorption and decreased appetite. High fever can occur during acute flare-ups but is not a primary finding of Crohn's disease.
Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?
Select the best answer.
Explanation:
Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.
Which of the following best describes the method of action of medications, such as ranitidine (Zantac), which are used in the treatment of peptic ulcer disease?
Select the best answer.
Explanation:
Medications like ranitidine (Zantac) are H2 receptor antagonists that reduce acid secretions in the stomach, helping to treat peptic ulcer disease.
Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?
Select the best answer.
Explanation:
Explain to the patient that the NG tube is used to empty the stomach of fluids and gas, which helps relieve symptoms of acute pancreatitis.
George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage?
Select the best answer.
Explanation:
Before discharge, inform the patient that the drainage will decrease daily until the bile duct heals.
A patient has an acute upper GI hemorrhage. Your interventions include:
Select the best answer.
Explanation:
For a patient with an acute upper GI hemorrhage, your interventions include treating shock and diagnosing the bleeding source.
A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?
Select the best answer.
Explanation:
Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur.
Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?
Select the best answer.
Explanation:
In a patient with acute pancreatitis and a history of alcohol abuse, glucose levels are most likely to be elevated.
Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
Select the best answer.
Explanation:
For a client with a small-bowel obstruction and a Miller-Abbott tube, deficient fluid volume is the priority nursing diagnosis.
A client with gastric cancer can expect to have surgery for resection. Which of the following should be the nursing management priority for the preoperative client with gastric cancer?
Select the best answer.
Explanation:
The priority for preoperative management of a client with gastric cancer is the correction of nutritional deficits.
A nurse teaches a preoperative client about the nasogastric tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed in the postoperative period when the client states
Select the best answer.
Explanation:
Nasogastric tubes are discontinued when normal function returns to the gastrointestinal tract. The tube will be removed before gastrointestinal healing. Food would not be administered unless bowel function returns. Although the physician determines when the nasogastric tube will be removed, option 4 does not determine effectiveness of teaching.
The nurse is caring for a client following a Billroth II procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify?
Select the best answer.
Explanation:
Irrigating the nasogastric tube is typically not recommended after a Billroth II procedure unless specifically ordered by a physician due to the risk of disrupting the surgical site.
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
Select the best answer.
Explanation:
After a cholecystectomy, teaching the client to use a folded blanket or pillow to splint the incision will be most effective in helping the client cough and deep breathe. This technique provides support and reduces pain during coughing and deep breathing, promoting better lung expansion. Having the client take rapid, shallow breaths would not be effective in decreasing pain; instead, deep breathing is encouraged to prevent complications like atelectasis. Lying on the left side would limit lung expansion; therefore, the client should be positioned in semi-Fowler's or Fowler's position to maximize lung expansion. Withholding pain medication can lead to discomfort and reluctance to cough and deep breathe, hindering recovery.
Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?
Select the best answer.
Explanation:
Care for a patient with diverticulosis includes a high-fiber diet and administration of psyllium.
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
Select the best answer.
Explanation:
A sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen indicates that the ulcer has perforated.
Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
Select the best answer.
Explanation:
For a patient with a possible bowel obstruction, measuring abdominal girth is a priority to monitor for signs of worsening obstruction or distention.
Mucosal barrier fortifiers are used in peptic ulcer disease management for which of the following indications?
Select the best answer.
Explanation:
Mucosal barrier fortifiers stimulate mucus production, which helps protect the lining of the stomach and manage peptic ulcer disease.
Fistulas are most common with which of the following bowel disorders?
Select the best answer.
Explanation:
Fistulas are most common in Crohn's disease due to the transmural inflammation that characterizes this condition.
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
Select the best answer.
Explanation:
When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.
Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,"If I lie still and avoid turning after the operation, I'll avoid pain. Do you think this is a good idea?" What is the best response?
Select the best answer.
Explanation:
The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.
The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
Select the best answer.
Explanation:
Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.
A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?
Select the best answer.
Explanation:
Placing the client in a high Fowler's position helps prevent aspiration and promotes proper digestion and feeding tube function.
A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?
Select the best answer.
Explanation:
The client should be assessed carefully for signs of hypokalemia, a common complication of prolonged ulcerative colitis symptoms.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
Select the best answer.
Explanation:
The client should take a deep breath because the client's airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.
Which of the following areas is the most common site of fistulas in clients with Crohn's disease?
Select the best answer.
Explanation:
The anorectal area is the most common site of fistulas in clients with Crohn's disease.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Select the best answer.
Explanation:
Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis?
Select the best answer.
Explanation:
A colonoscopy with biopsy is the most definitive diagnostic test to differentiate between Crohn's disease and ulcerative colitis.
The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?
Select the best answer.
Explanation:
Fasting for 8 hours ensures that the stomach is empty, which is necessary for an accurate barium swallow test.
After a subtotal gastrectomy, care of the client's nasogastric tube and drainage system should include which of the following nursing interventions?
Select the best answer.
Explanation:
Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.
You're performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
Select the best answer.
Explanation:
The correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation.
Fistulas are most common with which of the following bowel disorders?
Select the best answer.
Explanation:
Fistulas are most common in Crohn's disease due to the transmural inflammation that characterizes this condition.
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
Select the best answer.
Explanation:
When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will be obstructed temporarily during the tube removal. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.
Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,"If I lie still and avoid turning after the operation, I'll avoid pain. Do you think this is a good idea?" What is the best response?
Select the best answer.
Explanation:
The best response to Gail is to inform her that she will need to turn from side to side every 2 hours to prevent complications.
The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?
Select the best answer.
Explanation:
Tap water at body temperature is generally used for colostomy irrigation unless the local water supply is not safe for drinking, in which case bottled water can be used.
A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?
Select the best answer.
Explanation:
Placing the client in a high Fowler's position helps prevent aspiration and promotes proper digestion and feeding tube function.
A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?
Select the best answer.
Explanation:
The client should be assessed carefully for signs of hypokalemia, a common complication of prolonged ulcerative colitis symptoms.
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?
Select the best answer.
Explanation:
The client should take a deep breath because the client's airway will be obstructed temporarily during tube removal. The nurse then tells the client to exhale slowly and withdraws the tube during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal.
Which of the following areas is the most common site of fistulas in clients with Crohn's disease?
Select the best answer.
Explanation:
The anorectal area is the most common site of fistulas in clients with Crohn's disease.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
Select the best answer.
Explanation:
Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis?
Select the best answer.
Explanation:
A colonoscopy with biopsy is the most definitive diagnostic test to differentiate between Crohn's disease and ulcerative colitis.
The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?
Select the best answer.
Explanation:
Fasting for 8 hours ensures that the stomach is empty, which is necessary for an accurate barium swallow test.
After a subtotal gastrectomy, care of the client's nasogastric tube and drainage system should include which of the following nursing interventions?
Select the best answer.
Explanation:
Monitoring the client for nausea, vomiting, and abdominal distention is crucial for ensuring proper functioning of the nasogastric tube and drainage system.
You're performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
Select the best answer.
Explanation:
The correct order for performing an abdominal assessment is observation, auscultation, percussion, and palpation.
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