Medical-Surgical: Gastrointestinal Practice Quiz UPDATED ACTUAL Questions
And Correct Answers
C
Terms in this set (20)
A nurse is caring for a client who has a percutaneous Place the client in semi-Fowlers's position.
endoscopic gastrostomy (PEG) tube and is receiving
intermittent feedings. Prior to initiating the feeding, which Rationale: The nurse should apply the ABC priority-setting framework. This
of the following actions should the nurse take first? framework emphasizes the basic core of human functioning: having an open
- Flush the tube with water. airway, being able to breathe in adequate amounts of oxygen, and circulating
- Place the client in semi-Fowlers's position. oxygen to the body's organs via the blood. An alteration in any of these can
- Cleanse the skin around the tube site. indicate a threat to life and is therefore the nurse's priority concern. When
- Aspirate the tube for residual contents. 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 To detect an ulceration in the stomach
an esophagogastroduodenoscopy (EGD). The nurse
should identify that this procedure is used to do which of Rationale: An EGD is used to visualize the esophagus, stomach, and duodenum
the following? with a lighted tube to detect a tumor, ulceration, or obstruction.
- 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
A nurse is teaching a client who has Barrett's esophagus "This procedure can determine how well the lower part of your esophagus works."
and is scheduled to undergo an
esophagogastroduidenoscopy (EGD). Which of the Rationale: An EGD is useful in determining the function of the esophageal lining
following statements should the nurse include in the and the extent of inflammation, potential scarring, and strictures.
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."
, A nurse is caring for a client who is dehydrated and is The head of the bed is elevated 20°.
receiving continuous tube feeding through a pump at 75
mL/hr. When the nurse assesses the client at 0800, which Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's
of the following findings requires intervention by the position) while the tube feeding is administered. This position uses gravity to help
nurse? the feeding move down through the digestive system and lessens the possibility
- A full pitcher of water is sitting on the client's bedside of regurgitation.
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°.
A nurse is caring for a client who is receiving total Diaphoresis
parenteral nutrition (TPN) therapy and has just returned
to the room following physical therapy. The nurse notes Rationale: The nurse should recognize that the client has the potential for the
that the infusion pump for the client's TPN is turned off. development of hypoglycemia due to the sudden withdrawal of the TPN solution.
After restarting the infusion pump, the nurse should In addition to diaphoresis, other potential manifestations of hypoglycemia can
monitor the client for which of the following findings? include weakness, anxiety, confusion, and hunger.
- Hypertension
- Excessive thirst
- Fever
- Diaphoresis
A nurse is caring for a client who has celiac disease. Wheat toast
Which of the following foods should the nurse remove
from the client's meal tray? Rationale: Celiac disease is an autoimmune disorder characterized by a
- Wheat toast permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and
- Tapioca pudding should be removed from the client's tray.
- Hard-boiled egg
- Mash potatoes
And Correct Answers
C
Terms in this set (20)
A nurse is caring for a client who has a percutaneous Place the client in semi-Fowlers's position.
endoscopic gastrostomy (PEG) tube and is receiving
intermittent feedings. Prior to initiating the feeding, which Rationale: The nurse should apply the ABC priority-setting framework. This
of the following actions should the nurse take first? framework emphasizes the basic core of human functioning: having an open
- Flush the tube with water. airway, being able to breathe in adequate amounts of oxygen, and circulating
- Place the client in semi-Fowlers's position. oxygen to the body's organs via the blood. An alteration in any of these can
- Cleanse the skin around the tube site. indicate a threat to life and is therefore the nurse's priority concern. When
- Aspirate the tube for residual contents. 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 To detect an ulceration in the stomach
an esophagogastroduodenoscopy (EGD). The nurse
should identify that this procedure is used to do which of Rationale: An EGD is used to visualize the esophagus, stomach, and duodenum
the following? with a lighted tube to detect a tumor, ulceration, or obstruction.
- 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
A nurse is teaching a client who has Barrett's esophagus "This procedure can determine how well the lower part of your esophagus works."
and is scheduled to undergo an
esophagogastroduidenoscopy (EGD). Which of the Rationale: An EGD is useful in determining the function of the esophageal lining
following statements should the nurse include in the and the extent of inflammation, potential scarring, and strictures.
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."
, A nurse is caring for a client who is dehydrated and is The head of the bed is elevated 20°.
receiving continuous tube feeding through a pump at 75
mL/hr. When the nurse assesses the client at 0800, which Rationale: The head of the bed should be elevated at least 30° (semi-Fowler's
of the following findings requires intervention by the position) while the tube feeding is administered. This position uses gravity to help
nurse? the feeding move down through the digestive system and lessens the possibility
- A full pitcher of water is sitting on the client's bedside of regurgitation.
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°.
A nurse is caring for a client who is receiving total Diaphoresis
parenteral nutrition (TPN) therapy and has just returned
to the room following physical therapy. The nurse notes Rationale: The nurse should recognize that the client has the potential for the
that the infusion pump for the client's TPN is turned off. development of hypoglycemia due to the sudden withdrawal of the TPN solution.
After restarting the infusion pump, the nurse should In addition to diaphoresis, other potential manifestations of hypoglycemia can
monitor the client for which of the following findings? include weakness, anxiety, confusion, and hunger.
- Hypertension
- Excessive thirst
- Fever
- Diaphoresis
A nurse is caring for a client who has celiac disease. Wheat toast
Which of the following foods should the nurse remove
from the client's meal tray? Rationale: Celiac disease is an autoimmune disorder characterized by a
- Wheat toast permanent intolerance to wheat, barley, and rye. Wheat toast contains gluten and
- Tapioca pudding should be removed from the client's tray.
- Hard-boiled egg
- Mash potatoes
