ATI Medsurge GI Detailed Answer Key

1. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? A. Lower the height of the solution container. Rationale: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed. B. Encourage the client to bear down. Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema. C. Allow the client to expel some fluid before continuing. Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema. D. Stop the enema and document that the client did not tolerate the procedure. Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease the cramping. 2. A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? A. "Tuck your chin when you swallow so you won't choke." Rationale: Tucking the chin when swallowing helps prevent aspiration in clients who have dysphagia, but this is not a risk for this client. B. "It is no longer possible for you to choke on or aspirate food." Rationale: The surgical procedure of total laryngectomy provides complete anatomical separation of the trachea and esophagus. Choking and aspiration of food and liquids is no longer possible. C. "You should have no trouble swallowing fluids." Rationale: Immediately after NG tube removal, swallowing is usually uncomfortable. The client might need an analgesic prior to his initial attempts to swallow. D. "I will add a thickener to your liquids to prevent aspiration." Rationale: Thickening liquids helps prevent aspiration in clients who have dysphagia, but this is not a risk for this client. 3. A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." Rationale: This response is an example of unwarranted or false reassurance. It does not encourage the client to explain his feelings. B. "Before the examination, your provider will give you a sedative that will make you sleepy." Rationale: This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. C. "I know you’re anxious, but this procedure is recommended for people your age." Rationale: This statement is true. Routine screening for polyps and colon cancer is recommended starting at age 50; however, the nurse is changing the subject and this does not encourage the client to explain his feelings. D. "After you have signed the consent form, we can talk more about this." Rationale: The nurse should ensure that the client understands and agrees to the procedure before the client signs the consent form. 4. A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values? A. Calcium Rationale: The nurse should expect a decreased calcium level in a client who has acute pancreatitis. B. RBC count Rationale: The nurse should expect an elevated WBC count in a client who has acute pancreatitis. C. Magnesium Rationale: The nurse should expect to a decreased magnesium level in a client who has acute pancreatitis. D. Amylase Rationale: Amylase is an enzyme that changes complex sugars into simple sugars that can be used by the body. It is produced by the pancreas and salivary glands and released into the mouth, stomach, and intestines to aid in digestion. The amylase level of a client who has acute pancreatitis usually increases within 12 to 24 hr and can remain elevated for 2 to 3 days. 5. A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or “Hot Spots,” are outlined in the artwork below. Select only the outlined area that corresponds to your answer.) Answers cannot be displayed for this alternate item format. Rationale: McBurney's point is located by drawing a line from the navel to the right iliac crest. Divide the line into three equal lengths. McBurney's point is midway between the navel to the iliac crest. Pressure over this point will elicit pain in clients with appendicitis. 6. A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." Rationale: The client who has kidney stones should drink plenty of fluid to prevent the urine from becoming concentrated, which leads to stone formation. The nurse should instruct the client to drink fluids (primarily water) every 1-2 hr and drink enough to produce more than 2,000 mL of urine each day. B. "The last time I voided it was painful and red-tinged." Rationale: Manifestations of kidney stones depends upon the location of the stone but generally include flank pain, hematuria, and pyuria. Nausea and vomiting may also occur. C. "My period ended 2 days ago." Rationale: While x-ray is used for the IVP, a menstrual cycle that ended just 2 days prior to admission would make it highly unlikely that the client could be pregnant, and no special precautions need to be taken due to x-ray exposure. D. "I don't eat shellfish because it gives me hives." Rationale: The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.