NSG 233 Unit 8 P&D Gastrointestinal exam questions with complete verified solutions already graded A

An RN is the leader of a team caring for patients with gastrointestinal disorders on a medical-surgical unit. The team includes a newly graduated RN who has recently completed hospital orientation, an experienced assistive personal (AP), and a nursing student. The following information about the six assigned patients is included in the hand-off report. (Note to student: Use the information from the hand-off report to make brief notes about these six patients and refer to the notes as you work through the case study. This gives you practice in identifying important information and simulates how you would use the notes to remember and keep track of six patients over the course of a shift.) -Ms. H, a 42-year-old woman, has right upper quadrant pain that radiates to the right shoulder. She has a history of gallstones. She was admitted through the emergency department last night with acute cholecystitis. The night shift nurse reports, "She had a good night." -Ms. D, a 60-year-old woman, was admitted with vomiting and pain in the midabdomen related to a bowel obstruction. She reports abdominal pain that has gradually improved since the insertion of a nasogastric (NG) tube. She is receiving IV fluids and is currently NOP. -Ms. T, a 29-year-old woman, was admitted for an acute exacerbation of ulcerative colitis. She appears wasted and malnourished. She has severe diarrhea and reports predefecation abdominal pain and generalized tenderness to palpation. The plan is to start administering total parenteral nutrition (TPN) through a central line this morning. -Mr. A, a 26-year-old man, will be discharged in the afternoon. He is homeless and frequently sleeps in a nearby shelter. He had discharge teaching from the enterostomal therapist. Yesterday regarding his infected wound secondary to a ruptured appendix; he wants a review of the wound care instructions before he leaves. -Mr. K, an 85-year-old man, is frail but alert and oriented to person and place. He was transferred from an extended-care facility to receive a percutaneous endoscopic gastrostomy (PEG) tube that was placed 5 days ago. He has a large family. They ask a lot of questions and argue continuously among themselves and with the staff. His vital signs are stable. -Mr. R, a 57-year-old man, has periumbilical pain. The pain is very severe, despite medication, and radiates to the back. Mr. R was admitted with acute pancreatitis. He is NPO and has an NG tube and IV line. He is belligerent and confused. His white blood cell (WBC) count and blood glucose level are increased. ... The night shift nurse has just finished giving the RN team leader a report on the six patients. Which patient has the highest acuity level and the greatest risk for shock? 1. Ms. D (bowel obstruction) 2. Mr. R (acute pancreatitis) 3. Mr. A (appendectomy) 4. Ms. H (acute cholecystitis) 5. Mr. K (PEG tube) 6. Ms. T (ulcerative colitis) 2. Rational: Mr. R has acute pancreatitis and several prognostic factors that increase the risk for death: age older than 50 years, increased WBC count, and an elevated blood glucose level. Shock can occur secondary to bleeding; release of kinins, which cause vasodilation; or release of enzymes into the circulation. He is also at risk for infection and sepsis. Respiratory complications of pancreatitis include pneumonia, atelectasis, pleural effusions, and acute respiratory distress syndrome. Which patients would be best to assign to the new RN? Select all that apply. 1. Mr. K (PEG tube) 2. Ms. T (ulcerative colitis) 3. Ms. H (acute cholecystitis) 4. Mr. R (acute pancreatitis) 5. Ms. D (bowel obstruction) 6. Mr. A (appendectomy) 3, 5, 6 Rational: Ms. H, Ms. D, and Mr. A are in the most stable condition and represent the least complex cases according to the shift report. Mr. R's confusion and belligerence will make pain management especially difficult. Laboratory results and potential complications must be closely monitored. Ms. T is at risk for electrolyte imbalances, especially hypokalemia. She needs repetitive perineal hygiene and skin assessment. TPN and central line management require additional skills. Mr. K is in stable condition, but because of the family dynamics, his care should be handled by an experienced nurse. Which tasks can be delegated to the AP? Select all that apply. 1. Assisting Ms. T with perineal care after diarrheal episodes . 2. Transporting Ms. H off the unit for a procedure. 3. Gently cleansing the nares around Ms. D's NG tube. 4. Measuring vital signs every 2 hours for Mr. R. 5. Removing Mr. A's dressing. 6. Helping Mr. K brush his teeth. 1, 2, 3, 4, 6 Rational: Measuring vital signs, performing hygienic care, and transporting (stable) patients are within the scope of the AP's duties. The AP should not remove the dressing. If the dressing needs to be removed, the nurse should remove it, conduct the wound assessment, clean the area, and redress as needed. Which reporting tasks are appropriate to delegate to the AP? Select all that apply. 1. Reporting if any of the patients are complaining of pain . 2. Reporting on the condition of Ms. T's perineal area after application of ointment . 3. Reporting that Mr. K's family has questions . 4. Reporting the quality and color of NG drainage for Ms. D . 5. Reporting if Mr. A is seen leaving the unit to smoke a cigarette . 6. Reporting whether Mr. R's blood pressure is below 100/60 mm Hg . 1, 3, 5, 6 Rational: The AP can report on changes in vital sign values; giving parameters for notification is better than asking for general reports on any changes. The AP can report that a patient is having pain but is not expected to assess that pain. The AP can report that the family has questions but should not be expected to answer questions about the patient's care. All staff should be aware of when registered patients come and go on the unit and should keep each other advised. (Note: Patients should also be encouraged to tell someone if they are going off the unit.) Judging the response to treatment and evaluating drainage are responsibilities of the RN. The night nurse gives a brief and incomplete report. Which question should the oncoming RN team leader pose to the night shift nurse to help determine the priority actions for Ms. H, who was admitted for acute cholecystitis? A. "Is she going to surgery or radiology this morning?" B. "Does she need any morning medications?" C. "What are her vital signs?" D. "Is she still having pain?" A. "Is she going to surgery or radiology this morning?" Rational: When the shift report is incomplete, the nurse can ask for any type of additional information; however, morning surgery or procedures impact the immediate plan of care for the individual patient and the organization of care for other assigned patients. HCPs frequently communicate verbally to the nursing staff, but the written notes may be pending, especially if it is an emergency admission or if the HCP is trying to complete rounds or do procedures. Vital sign values and the need for medications can be obtained from the records if the off-going nurse neglects to give that information. A current pain report can and should be obtained directly from the patient. It is confirmed that Ms. H needs to have an endoscopic retrograde cholangiopancreatography (ERCP) this morning. While preparing the patient to go to the procedure, the nurse discovers the following information. Which finding is the most urgent to report to the health care provider (HCP)? A. Ms. H reveals that she is supposed to be taking medication for high blood pressure. B. Ms. H reports that she had "some type of reaction" to contrast media in the past. C. Ms. H has been hesitant to sign the consent form and the form is still unsigned. D. Ms. H has several sudden episodes of vomiting large amounts of green bile emesis. C. Ms. H has been hesitant to sign the consent form and the form is still unsigned. Rational: An absolute contraindication would be an unsigned consent form. If a patient makes new disclosures about medical history (e.g., untreated conditions or history of untoward effects), these require further investigation before the procedure begins. Nausea and vomiting are not uncommon during acute cholecystitis, and the HCP may order NG tube insertion to decompress the stomach to reduce the risk for aspiration. Ms. H decided to have the ERCP. The procedure was successfully performed without incident and she returns to the medical-surgical unit. What is the priority assessment in the immediate postprocedural care? A. Signs/symptoms of an allergic reaction B. Signs/symptoms of biliary colic C. Signs/symptoms of pancreatitis D. Signs/symptoms of perforation D. S/S of perforation Rational: Perforation is the major complication that can occur during any type of endoscopic procedure. The nurse would assess for signs/symptoms, such as abdominal pain, distention, nausea, vomiting, fever, and shock. Pancreatitis is the most common complication; however, the pathogenesis of pancreatitis will develop more slowly. Assessment for pancreatitis will become the priority after the immediate dangers of airway obstruction (return of gag reflex and independent control of airway) and perforation (hemorrhage and peritonitis) are passed. Severe anaphylactic reactions to contrast media would be expected to occur immediately after administration. Delayed reactions may occur but are much less severe. Biliary colic (severe pain, tachycardia, diaphoresis, and prostration) could occur when gallstones are dislodged and move through the ducts; however, biliary colic is not expected after the procedure. Ms. H's (acute cholecystitis) ERCP shows a decreased bile flow with gallbladder disease and obstruction. Because of the obstruction, the nurse is vigilant for the complication of biliary colic. What are the key signs and symptoms that the nurse will watch for? A. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration . B. Flatulence, dyspepsia, and eructation after eating or drinking . C. RUQ abdominal pain that radiates to the right shoulder or scapula . D. Rebound tenderness and a sausage-shaped mass in the right upper quadrant (RUQ) . A. Severe abdominal pain with tachycardia, pallor, diaphoresis, and prostration . Rational: Severe pain with tachycardia, pallor, diaphoresis, and prostration (exhaustion) are signs and symptoms of severe biliary colic. Keep the patient flat and notify the rapid response team because of the potential for shock. Rebound tenderness and a sausage-shaped mass in the RUQ suggest peritoneal inflammation. Flatulence (gas), dyspepsia (indigestion), and eructation (belching) after eating are commonly reported by patients when they first seek help for gallbladder problems. RUQ pain that radiates to the right shoulder or scapula is reported by some patients in their descriptions of pain patterns. The HCP told Ms. H (acute cholecystitis) that she would probably need a laparoscopic cholecystectomy; however, the ERCP and laboratory results are still pending. Ms. H asks, "What should I expect?" What is the best intervention at this point? A. Provide some written material about gallbladder disease and options. B. Describe the surgical procedure. C. Call the HCP to come and speak with her. D. Explain general postoperative care, such as coughing and deep breathing exercises. A. Provide some written material about gallbladder disease and options. Rational: Giving written information about gallbladder disease and options will help Ms. H to prepare any questions she might have for the HCP. If diagnostic results are pending, calling the HCP is premature. Describing the surgical procedure is inappropriate because there is more than one type of procedure, and the one to be used is still undetermined. Explaining postoperative care would be appropriate after the need for cholecystectomy has been verified by the HCP. All of these patients must receive their routine morning medications. Which patient should receive his or her medication last? A. Ms. H (acute cholecystitis) B. Ms. D (bowel obstruction) C. Mr. K (PEG tube) D. Ms. T (ulcerative colitis) C. Mr. K Rational: In the provision of routine care and when all patients are stable, patients who need extra time should be left until last so that care for others is not delayed. Mr. K will require more time and assistance because of age and weakness. Also, his medications must be crushed and administered via PEG tube, which is more time consuming. Dealing with Mr. K's family is also more time consuming. Older adult patients and their families typically benefit from and appreciate caregivers who do not act rushed or hurried. The RN is observing the nursing student perform an abdominal assessment on Ms. D, who was admitted for a bowel obstruction. For which actions will the supervising nurse intervene? Select all that apply. 1. Palpating for abdominal distention with the index fingertip. 2. Checking for skin turgor over the lower abdominal area. 3. Inspecting for visible signs of peristaltic waves or abdominal distention. 4. Auscultating for bowel sounds with the NG tube attached to low wall suction. 5. Checking the NG collection canister for quantity and quality of drainage. 6. Performing the physical assessment before asking about pain. 1, 2, 4, 6 Rational: The flat palmar surface of the hand is better than the fingertips when palpating for distention. If the wall suction is activated, it will interfere with auscultating for bowel sounds. Asking about pain will guide the physical assessment steps. The skin on the anterior chest under the clavicle is a better place to check for turgor than the lower abdomen, especially if abdominal distention is present. Checking the drainage and inspecting for peristaltic waves or distention are correct actions.