Ignatavicius Ch 52: Assessment of the Gastrointestinal System Flashcards
- 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
b. Liquefied food ready for digestion
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 bodys circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
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.
a. Ask the client about shellfish allergies.
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.
A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The clients 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.
c. Provide physical stimulation.
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 nurses 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.
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. Its 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.
a. Its a good thing I love orange and cherry gelatin.
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.
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.
c. Remind the client that a small amount of bleeding is possible.
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.
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 dont 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 cant tolerate as much medication anymore.
a. Changes in your liver cause drugs to be metabolized differently.
Decreased liver enzyme activity depresses drug metabolism, which leads to accumulation of drugspossibly to toxic levels. The other options do not accurately explain this age-related change.
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
a. Left lateral
After colonoscopy, clients have less discomfort and quicker passage of flatus when placed in the left lateral position.
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?
a. Auscultate after palpating.
b. Avoid any palpation.
c. Palpate the RUQ first.
d. Palpate the RUQ last.
d. Palpate the RUQ last.
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.
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.
b. Notify the provider immediately.
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 nurses priority action is to notify the provider.
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 clients stool for obvious food particles.
c. Include the date and time on the specimen container.
d. Put on gloves prior to collecting the sample.
d. Put on gloves prior to collecting the sample.
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.
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
b. Enzyme-linked immunosorbent assay (ELISA) toxin A+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 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
b. Liver
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.
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 clients gag reflex.
c. Remind the client to remain NPO.
d. Tell the client to wait 4 hours.
b. Assess the clients gag reflex.
The local anesthetic used during this procedure will depress the clients 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 clients readiness for them.
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
a. Colonoscopy every 10 years
c. Computed tomography (CT) colonography every 5 years
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.
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
a. Cholangitis
b. Pancreatitis
c. Perforation
e. Sepsis
Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.
