Medical-Surgical: Gastrointestinal Practice
Quiz
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube
and is receiving intermittent feedings. Prior to initiating the feeding, which of the following
actions should the nurse take first?
- Flush the tube with water.
- Place the client in semi-Fowlers's position.
- Cleanse the skin around the tube site.
- Aspirate the tube for residual contents. - ANS Place the client in semi-Fowlers's position.
Rationale: The nurse should apply the ABC priority-setting framework. This framework
emphasizes the basic core of human functioning: having an open airway, being able to
breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the
blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's
priority concern. When applying the ABC priority-setting framework, airway is always the
highest priority because the airway must be clear and open for oxygen exchange to occur.
Breathing is the second priority in the ABC priority-setting framework because adequate
ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in
the ABC priority-setting framework because delivery of oxygen to critical organs only occurs
if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client
who is receiving PEG tube feedings should be positioned with the head of the bed elevated
at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the
priority action by the nurse.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy
(EGD). The nurse should identify that this procedure is used to do which of the following?
- To visualize polyps in the colon
- To detect an ulceration in the stomach
- To identify an obstruction in the biliary tract
- To determine the presence of free air in the abdomen - ANS To detect an ulceration in the
stomach
, Rationale: An EGD is used to visualize the esophagus, stomach, and duodenum with a
lighted tube to detect a tumor, ulceration, or obstruction.
A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an
esophagogastroduidenoscopy (EGD). Which of the following statements should the nurse
include in the teaching?
- "This procedure is performed to measure the presence of acid in your esophagus."
- "This procedure can determine how well the lower part of your esophagus works."
- "This procedure is performed while you are under general anesthesia."
- "This procedure can determine if you have colon cancer." - ANS "This procedure can
determine how well the lower part of your esophagus works."
Rationale: An EGD is useful in determining the function of the esophageal lining and the
extent of inflammation, potential scarring, and strictures.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding
through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the
following findings requires intervention by the nurse?
- A full pitcher of water is sitting on the client's bedside table within the client's reach.
- The disposable feeding bag is from the previous day at 1000 and contains 200 mL of
feeding.
- The client is lying on the right side with a visible dependent loop in the feeding tube.
- The head of the bed is elevated 20°. - ANS The head of the bed is elevated 20°.
Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's position)
while the tube feeding is administered. This position uses gravity to help the feeding move
down through the digestive system and lessens the possibility of regurgitation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and
has just returned to the room following physical therapy. The nurse notes that the infusion
pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should
monitor the client for which of the following findings?
- Hypertension
- Excessive thirst
- Fever
- Diaphoresis - ANS Diaphoresis
Quiz
A nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube
and is receiving intermittent feedings. Prior to initiating the feeding, which of the following
actions should the nurse take first?
- Flush the tube with water.
- Place the client in semi-Fowlers's position.
- Cleanse the skin around the tube site.
- Aspirate the tube for residual contents. - ANS Place the client in semi-Fowlers's position.
Rationale: The nurse should apply the ABC priority-setting framework. This framework
emphasizes the basic core of human functioning: having an open airway, being able to
breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the
blood. An alteration in any of these can indicate a threat to life and is therefore the nurse's
priority concern. When applying the ABC priority-setting framework, airway is always the
highest priority because the airway must be clear and open for oxygen exchange to occur.
Breathing is the second priority in the ABC priority-setting framework because adequate
ventilatory effort is essential for oxygen exchange to occur. Circulation is the third priority in
the ABC priority-setting framework because delivery of oxygen to critical organs only occurs
if the heart and blood vessels are capable of efficiently carrying oxygen to them. A client
who is receiving PEG tube feedings should be positioned with the head of the bed elevated
at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the
priority action by the nurse.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy
(EGD). The nurse should identify that this procedure is used to do which of the following?
- To visualize polyps in the colon
- To detect an ulceration in the stomach
- To identify an obstruction in the biliary tract
- To determine the presence of free air in the abdomen - ANS To detect an ulceration in the
stomach
, Rationale: An EGD is used to visualize the esophagus, stomach, and duodenum with a
lighted tube to detect a tumor, ulceration, or obstruction.
A nurse is teaching a client who has Barrett's esophagus and is scheduled to undergo an
esophagogastroduidenoscopy (EGD). Which of the following statements should the nurse
include in the teaching?
- "This procedure is performed to measure the presence of acid in your esophagus."
- "This procedure can determine how well the lower part of your esophagus works."
- "This procedure is performed while you are under general anesthesia."
- "This procedure can determine if you have colon cancer." - ANS "This procedure can
determine how well the lower part of your esophagus works."
Rationale: An EGD is useful in determining the function of the esophageal lining and the
extent of inflammation, potential scarring, and strictures.
A nurse is caring for a client who is dehydrated and is receiving continuous tube feeding
through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which of the
following findings requires intervention by the nurse?
- A full pitcher of water is sitting on the client's bedside table within the client's reach.
- The disposable feeding bag is from the previous day at 1000 and contains 200 mL of
feeding.
- The client is lying on the right side with a visible dependent loop in the feeding tube.
- The head of the bed is elevated 20°. - ANS The head of the bed is elevated 20°.
Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's position)
while the tube feeding is administered. This position uses gravity to help the feeding move
down through the digestive system and lessens the possibility of regurgitation.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and
has just returned to the room following physical therapy. The nurse notes that the infusion
pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should
monitor the client for which of the following findings?
- Hypertension
- Excessive thirst
- Fever
- Diaphoresis - ANS Diaphoresis
