Chapter 44: Nursing Management: Upper
Gastrointestinal Problems Lewis et al.:
Medical-Surgical Nursing in Canada, 3rd
Edition
1. Which data approximately a patient who has simply been admitted to the clinic with nausea
and vomiting would require the most fast nursing intervention?
A. The affected person has been vomiting numerous times an afternoon for the last 4 days.
B. The affected person is lethargic and tough to arouse.
C. The patient's chart indicates a current resection of the small gut.
D. The patient has taken best sips of water. - ANS-ANS: B
A lethargic patient is at risk for aspiration, and the nurse will want to put the patient to decrease
aspiration threat.
PTS: 1 DIF: Cognitive Level: Application REF: page 1115
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-20
2. What is the place of the vomiting centre that coordinates the multiple components concerned
in vomiting?
A. Chemoreceptor sector
b. Brainstem
c. Vestibular area
d. Visceral receptors from afferent fibres inside the gastrointestinal (GI) tract - ANS-ANS: B
The vomiting centre inside the brainstem coordinates the more than one additives worried in
vomiting.
PTS: 1 DIF: Cognitive Level: Knowledge REF: page 1114
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-eight
three. The nurse identifies the nursing prognosis of deficient fluid quantity for a affected person
with extended vomiting. Which of the subsequent nursing assessments is maximum beneficial
in figuring out the supply of the vomiting?
A. Ask the times whilst the vomiting takes place.
B. Determine the amount and character of the vomitus.
C. Measure the consumption and output, and every day weight styles.
D. Assess the serum sodium, potassium, and chloride tiers. - ANS-ANS: A
When assessing vomiting, it's miles essential for the nurse to evaluate whilst the vomiting
happens to assist in expertise the cause.
, PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1115
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-1
4. A affected person who has been on nothing by way of mouth (NPO) repute throughout
treatment for nausea and vomiting related to gastric irritation is to start oral consumption of
clean beverages. To promote tolerance to oral fluids, what should the nurse first provide the
affected person?
A. Orange juice
b. Hot hen broth
c. A dish of lemon gelatin
d. Coffee with cream and sugar - ANS-ANS: C
Clear liquids are typically the primary meals began after a affected person has been nauseated.
Acidic meals which include orange juice, very warm foods, and espresso are poorly tolerated
while patients have been nauseated.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1116
OBJ: 1 TOP: Nursing Process: Implementation MSC: CRNE: CH-34
five. When a affected person with chronic nausea and severe vomiting is admitted to the
hospital for manage of the symptoms, what is the primary order that the nurse ought to act on?
A. Provide oral care with moistened swabs.
B. Infuse ordinary saline at 250 mL/hour.
C. Insert a 16-gauge nasogastric (NG) tube.
D. Administer intravenous (IV) ondansetron (Zofran). - ANS-ANS: B
Because the affected person has severe dehydration, rehydration with IV fluids is the concern.
The other orders have to be carried out as speedy as possible after the IV fluids are initiated.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1115
OBJ: 1 TOP: Nursing Process: Planning MSC: CRNE: CH-22
6. A patient who is on NPO fame and has been receiving parenteral vitamins for 2 weeks
develops bilateral ache within the area of the ears. The nurse recognizes that the patient is at
risk for improvement of which of the subsequent conditions?
A. Parotitis
b. Stomatitis
c. Oral candidiasis
d. Vincent's contamination (trench mouth) - ANS-ANS: A
Clinical manifestations of parotitis consist of ache and swelling within the location of the gland
and ear, absence of salivation, purulent exudate from the gland, erythema, and ulcer.
PTS: 1 DIF: Cognitive Level: Comprehension REF: page 1119, Table forty four-three
OBJ: 2 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
7. The nurse teaches a affected person who is attempting to forestall the use of smokeless
tobacco to study the mouth routinely for the threat signs of oral cancer, specifically for the
presence of which of the following symptoms?
A. Acutely sore ulcers
b. A crimson, velvety patch
Gastrointestinal Problems Lewis et al.:
Medical-Surgical Nursing in Canada, 3rd
Edition
1. Which data approximately a patient who has simply been admitted to the clinic with nausea
and vomiting would require the most fast nursing intervention?
A. The affected person has been vomiting numerous times an afternoon for the last 4 days.
B. The affected person is lethargic and tough to arouse.
C. The patient's chart indicates a current resection of the small gut.
D. The patient has taken best sips of water. - ANS-ANS: B
A lethargic patient is at risk for aspiration, and the nurse will want to put the patient to decrease
aspiration threat.
PTS: 1 DIF: Cognitive Level: Application REF: page 1115
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-20
2. What is the place of the vomiting centre that coordinates the multiple components concerned
in vomiting?
A. Chemoreceptor sector
b. Brainstem
c. Vestibular area
d. Visceral receptors from afferent fibres inside the gastrointestinal (GI) tract - ANS-ANS: B
The vomiting centre inside the brainstem coordinates the more than one additives worried in
vomiting.
PTS: 1 DIF: Cognitive Level: Knowledge REF: page 1114
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-eight
three. The nurse identifies the nursing prognosis of deficient fluid quantity for a affected person
with extended vomiting. Which of the subsequent nursing assessments is maximum beneficial
in figuring out the supply of the vomiting?
A. Ask the times whilst the vomiting takes place.
B. Determine the amount and character of the vomitus.
C. Measure the consumption and output, and every day weight styles.
D. Assess the serum sodium, potassium, and chloride tiers. - ANS-ANS: A
When assessing vomiting, it's miles essential for the nurse to evaluate whilst the vomiting
happens to assist in expertise the cause.
, PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1115
OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-1
4. A affected person who has been on nothing by way of mouth (NPO) repute throughout
treatment for nausea and vomiting related to gastric irritation is to start oral consumption of
clean beverages. To promote tolerance to oral fluids, what should the nurse first provide the
affected person?
A. Orange juice
b. Hot hen broth
c. A dish of lemon gelatin
d. Coffee with cream and sugar - ANS-ANS: C
Clear liquids are typically the primary meals began after a affected person has been nauseated.
Acidic meals which include orange juice, very warm foods, and espresso are poorly tolerated
while patients have been nauseated.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1116
OBJ: 1 TOP: Nursing Process: Implementation MSC: CRNE: CH-34
five. When a affected person with chronic nausea and severe vomiting is admitted to the
hospital for manage of the symptoms, what is the primary order that the nurse ought to act on?
A. Provide oral care with moistened swabs.
B. Infuse ordinary saline at 250 mL/hour.
C. Insert a 16-gauge nasogastric (NG) tube.
D. Administer intravenous (IV) ondansetron (Zofran). - ANS-ANS: B
Because the affected person has severe dehydration, rehydration with IV fluids is the concern.
The other orders have to be carried out as speedy as possible after the IV fluids are initiated.
PTS: 1 DIF: Cognitive Level: Comprehension REF: web page 1115
OBJ: 1 TOP: Nursing Process: Planning MSC: CRNE: CH-22
6. A patient who is on NPO fame and has been receiving parenteral vitamins for 2 weeks
develops bilateral ache within the area of the ears. The nurse recognizes that the patient is at
risk for improvement of which of the subsequent conditions?
A. Parotitis
b. Stomatitis
c. Oral candidiasis
d. Vincent's contamination (trench mouth) - ANS-ANS: A
Clinical manifestations of parotitis consist of ache and swelling within the location of the gland
and ear, absence of salivation, purulent exudate from the gland, erythema, and ulcer.
PTS: 1 DIF: Cognitive Level: Comprehension REF: page 1119, Table forty four-three
OBJ: 2 TOP: Nursing Process: Assessment MSC: CRNE: CH-8
7. The nurse teaches a affected person who is attempting to forestall the use of smokeless
tobacco to study the mouth routinely for the threat signs of oral cancer, specifically for the
presence of which of the following symptoms?
A. Acutely sore ulcers
b. A crimson, velvety patch
