Med surg Exam 3 (GI) with Accurate
Solutions
A nurse is providing discharge teaching for a client who has GERD. Which of the
following statements by the client indicates an understanding of the teaching? - ANS-A.
"I will decrease the amount of carbonated beverages I drink."
-The nurse should instruct the client to limit or eliminate fatty foods, coffee, cola, tea,
carbonated beverages, & chocolate from his diet because they irrigate the lining of the
stomach. Client should drink a glass of water immediately after taking an antacid tablet.
The client should eat 4-6 small meals/day & avoid snacking before bed. Client should sit
upright for 1-2 hr after meals.
A nurse is teaching a client how to prepare for a colonoscopy. Which of the following
instructions should the nurse include in the teaching? - ANS-C. Drink clear liquids for 24
hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure.
-The nurse should instruct the client to drink clear liquids for 24 hr prior to the
colonoscopy to promote adequate bowel cleansing. Maintaining NPO status for 4-6 hr
prior to the colonoscopy preserves the bowel's cleansed state. Client needs to drink oral
liquid preparation the day before the colonoscopy to ensure adequate time for bowel
cleansing. Client should drink the oral liquid preparation quickly to prevent nausea.
A nurse is admitting a client who has acute pancreatitis. Which of the following actions
should the nurse take first? - ANS-C. Identify the client's current level of pain.
-The first action the nurse should take when using the nursing process is to assess the
client. Clients who have acute pancreatitis often have severe abdominal pain. By
assessing the client's level of pain, the nurse can identify the need for and implement
interventions to alleviate the client's pain.
A nurse is assessing a client who has appendicitis. Which of the following findings
should the nurse expect? (Select all that apply) - ANS-A. Oral temp 38.4C (101.1F)D.
Nausea and vomitingE. Right lower quadrant pain
-Low-grade temperature, nausea and vomiting, and right lower quadrant pain are
expected. WBC 10,000-18,000/mm3 is expected and bloody diarrhea (sign of colorectal
cancer) is NOT expected.
A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which
of the following findings should the nurse expect? - ANS-D. Hemoglobin 9.1 g/dL
,-Decreased Hgb is an expected finding in pt with colorectal cancer bc of occult intestinal
bleeding. Fecal occult blood test should be positive bc colorectal cancer causes GI
bleeding. Elevated CEA level is expected. Hct 43% is w/in expected reference range,
hct should be decreased due to occult intestinal bleeding.
A nurse is assessing a client who has peritonitis. Which of the following findings should
the nurse expect? - ANS-B. Board-like abdomen
-A board-like, distended abdomen, accompanied by extreme pain and tenderness, is
expected. Bloody diarrhea = colorectal cancer, periumbilical cyanosis = pancreatitis,
diminished bowel sounds = peritonitis
A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which
of the following laboratory findings should the nurse report to the provider? - ANS-D.
Ammonia 180 mcg/dL
-Above expected reference range of 10-80 mcg/dL. The RN should report an increased
serum ammonia level b/c it can indicate port-systemic encephalopathy.
A nurse is assessing a client who has acute hepatitis B. Which of the following findings
should the nurse expect? - ANS-A. Joint pain
-Obstipation (failure to pass stools) = complete bowel obstruction, abdominal distention
= small bowel obstruction, periumbilical discoloration = intraperitoneal bleeding.
A nurse is assessing a client who has upper gastrointestinal bleeding. Which of the
following findings should the nurse expect? - ANS-C. Hypotension
-Pt w/ upper GI bleeding is at risk for hemorrhagic shock. Hypotension, tachycardia,
weak peripheral pulses, and decreased hematocrit and hemoglobin levels are
manifestations of hemorrhagic shock.
A nurse is caring for a client who has ulcerative colitis. The client has had several
exacerbations over the past 3 years. Which of the following instructions should the
nurse include in the plan of care to minimize the risk of further exacerbations? (Select
all that apply.) - ANS-A. Use progressive relaxation techniques.D. Arrange activities to
allow for daily rest periods.E. Restrict intake of carbonated beverages.
-Progressive relaxation techniques (biofeedback) minimize stress (exacerbation),
increased dietary fiber causes diarrhea and cramping, dairy products are poorly
tolerated and should be avoided, daily rest periods decrease stress and increase
intestinal motility, and pt needs to avoid GI stimulants (carbonated beverages, nuts,
peppers, and smoking).
, A nurse is assessing a client immediately following a paracentesis for the treatment of
ascites. Which of the following findings indicates the procedure was effective? - ANS-D.
Decreased shortness of breath
-Increased abdominal fluid can limit the expansion of the diaphragm and prevent the pt
from taking a deep breath. Once excess peritoneal fluid is removed, the diaphragm will
expand more freely. The nurse should identify this finding as an indicator the procedure
was effective.
A nurse is assessing a client who has Crohn's disease. Which of the following findings
should the nurse expect? - ANS-A. Fatty diarrheal stools
-Steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease.
Hypokalemia, weight loss, abdominal pain in right lower quadrant are expected findings.
A nurse is caring for a client who has a duodenal ulcer. Which of the following findings
should the nurse expect? - ANS-D. The client reports that pain occurs during the night.
-Pain associated w/ a duodenal ulcer occurs when the stomach is empty, typically 1.5-3
hr after meals and during the night. Ingesting food diminishes pain level, typically not
malnourished, pain is usually located below/rt of epigastrium.
A nurse is providing discharge teaching for an older adult client who has mild
diverticulitis. Which of the following statements by the client indicates an understanding
of the teaching? - ANS-C. "I should eat foods that are low in fiber."
-The nurse should instruct the pt to follow a low-fiber diet. When inflammation subsides,
the pt should consume foods high in fiber. Pain is expected in left lower quadrant, pt
should refrain from activity that increases intra-abdominal pressure bc it can cause
perforation of the diverticula, and pt should avoid laxatives (increase intestinal motility
and exacerbate adverse effects).
A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of
the following interventions should the nurse include in the plan? - ANS-A. Measure the
client's abdominal girth daily.
-Abdominal girth and weight should be monitored daily to monitor the amount of fluid
accumulation in the abdomen and effectiveness of Tx measures. Mental status should
be assessed every 4-8 hr (risk for hepatic encephalopathy), 1-2 g sodium restricted to
diet (prevent ascites), breath sounds should be monitored every 4-8 hr (risk for
dyspnea).
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which
of the following findings should the nurse expect? - ANS-B. Increased serum amylase
Solutions
A nurse is providing discharge teaching for a client who has GERD. Which of the
following statements by the client indicates an understanding of the teaching? - ANS-A.
"I will decrease the amount of carbonated beverages I drink."
-The nurse should instruct the client to limit or eliminate fatty foods, coffee, cola, tea,
carbonated beverages, & chocolate from his diet because they irrigate the lining of the
stomach. Client should drink a glass of water immediately after taking an antacid tablet.
The client should eat 4-6 small meals/day & avoid snacking before bed. Client should sit
upright for 1-2 hr after meals.
A nurse is teaching a client how to prepare for a colonoscopy. Which of the following
instructions should the nurse include in the teaching? - ANS-C. Drink clear liquids for 24
hr prior to the procedure, and then take nothing by mouth for 6 hr before the procedure.
-The nurse should instruct the client to drink clear liquids for 24 hr prior to the
colonoscopy to promote adequate bowel cleansing. Maintaining NPO status for 4-6 hr
prior to the colonoscopy preserves the bowel's cleansed state. Client needs to drink oral
liquid preparation the day before the colonoscopy to ensure adequate time for bowel
cleansing. Client should drink the oral liquid preparation quickly to prevent nausea.
A nurse is admitting a client who has acute pancreatitis. Which of the following actions
should the nurse take first? - ANS-C. Identify the client's current level of pain.
-The first action the nurse should take when using the nursing process is to assess the
client. Clients who have acute pancreatitis often have severe abdominal pain. By
assessing the client's level of pain, the nurse can identify the need for and implement
interventions to alleviate the client's pain.
A nurse is assessing a client who has appendicitis. Which of the following findings
should the nurse expect? (Select all that apply) - ANS-A. Oral temp 38.4C (101.1F)D.
Nausea and vomitingE. Right lower quadrant pain
-Low-grade temperature, nausea and vomiting, and right lower quadrant pain are
expected. WBC 10,000-18,000/mm3 is expected and bloody diarrhea (sign of colorectal
cancer) is NOT expected.
A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which
of the following findings should the nurse expect? - ANS-D. Hemoglobin 9.1 g/dL
,-Decreased Hgb is an expected finding in pt with colorectal cancer bc of occult intestinal
bleeding. Fecal occult blood test should be positive bc colorectal cancer causes GI
bleeding. Elevated CEA level is expected. Hct 43% is w/in expected reference range,
hct should be decreased due to occult intestinal bleeding.
A nurse is assessing a client who has peritonitis. Which of the following findings should
the nurse expect? - ANS-B. Board-like abdomen
-A board-like, distended abdomen, accompanied by extreme pain and tenderness, is
expected. Bloody diarrhea = colorectal cancer, periumbilical cyanosis = pancreatitis,
diminished bowel sounds = peritonitis
A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which
of the following laboratory findings should the nurse report to the provider? - ANS-D.
Ammonia 180 mcg/dL
-Above expected reference range of 10-80 mcg/dL. The RN should report an increased
serum ammonia level b/c it can indicate port-systemic encephalopathy.
A nurse is assessing a client who has acute hepatitis B. Which of the following findings
should the nurse expect? - ANS-A. Joint pain
-Obstipation (failure to pass stools) = complete bowel obstruction, abdominal distention
= small bowel obstruction, periumbilical discoloration = intraperitoneal bleeding.
A nurse is assessing a client who has upper gastrointestinal bleeding. Which of the
following findings should the nurse expect? - ANS-C. Hypotension
-Pt w/ upper GI bleeding is at risk for hemorrhagic shock. Hypotension, tachycardia,
weak peripheral pulses, and decreased hematocrit and hemoglobin levels are
manifestations of hemorrhagic shock.
A nurse is caring for a client who has ulcerative colitis. The client has had several
exacerbations over the past 3 years. Which of the following instructions should the
nurse include in the plan of care to minimize the risk of further exacerbations? (Select
all that apply.) - ANS-A. Use progressive relaxation techniques.D. Arrange activities to
allow for daily rest periods.E. Restrict intake of carbonated beverages.
-Progressive relaxation techniques (biofeedback) minimize stress (exacerbation),
increased dietary fiber causes diarrhea and cramping, dairy products are poorly
tolerated and should be avoided, daily rest periods decrease stress and increase
intestinal motility, and pt needs to avoid GI stimulants (carbonated beverages, nuts,
peppers, and smoking).
, A nurse is assessing a client immediately following a paracentesis for the treatment of
ascites. Which of the following findings indicates the procedure was effective? - ANS-D.
Decreased shortness of breath
-Increased abdominal fluid can limit the expansion of the diaphragm and prevent the pt
from taking a deep breath. Once excess peritoneal fluid is removed, the diaphragm will
expand more freely. The nurse should identify this finding as an indicator the procedure
was effective.
A nurse is assessing a client who has Crohn's disease. Which of the following findings
should the nurse expect? - ANS-A. Fatty diarrheal stools
-Steatorrhea, or fatty stool, is an expected finding in a client who has Crohn's disease.
Hypokalemia, weight loss, abdominal pain in right lower quadrant are expected findings.
A nurse is caring for a client who has a duodenal ulcer. Which of the following findings
should the nurse expect? - ANS-D. The client reports that pain occurs during the night.
-Pain associated w/ a duodenal ulcer occurs when the stomach is empty, typically 1.5-3
hr after meals and during the night. Ingesting food diminishes pain level, typically not
malnourished, pain is usually located below/rt of epigastrium.
A nurse is providing discharge teaching for an older adult client who has mild
diverticulitis. Which of the following statements by the client indicates an understanding
of the teaching? - ANS-C. "I should eat foods that are low in fiber."
-The nurse should instruct the pt to follow a low-fiber diet. When inflammation subsides,
the pt should consume foods high in fiber. Pain is expected in left lower quadrant, pt
should refrain from activity that increases intra-abdominal pressure bc it can cause
perforation of the diverticula, and pt should avoid laxatives (increase intestinal motility
and exacerbate adverse effects).
A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of
the following interventions should the nurse include in the plan? - ANS-A. Measure the
client's abdominal girth daily.
-Abdominal girth and weight should be monitored daily to monitor the amount of fluid
accumulation in the abdomen and effectiveness of Tx measures. Mental status should
be assessed every 4-8 hr (risk for hepatic encephalopathy), 1-2 g sodium restricted to
diet (prevent ascites), breath sounds should be monitored every 4-8 hr (risk for
dyspnea).
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which
of the following findings should the nurse expect? - ANS-B. Increased serum amylase
