Saunders NCLEX Med-Surg Gastrointestinal Patients NCLEX Exam (2 of 3)

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube? 1. Sodium 2. Creatinine 3. Hemoglobin 4. Ammonia - 3 ~ A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss. The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? 1. Hematemesis 2. Bloody diarrhea 3. Swelling of the abdomen 4. An elevated temperature and a rise in blood pressure - 1 ~ A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The remaining options are unrelated to deflating the esophageal balloon. A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? 1. "Do you want to stay here in this facility for a few more days?" 2. "Have you discussed your feelings with your health care provider?" 3. "You need to talk to your health care provider about these concerns." 4. "Tell me more about your concerns with your diet after going home." - 4 ~ A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about . . ." often leads to valuable information about the client and his concerns. The statements in the remaining options are nontherapeutic. The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? 1. "I have epigastric pain radiating to my neck." 2. "I have severe abdominal pain that is relieved after vomiting." 3. "My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)." 4. "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting." - 4 ~ Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign. Epigastric pain radiating to the neck area is not a characteristic symptom. The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask? 1. "Do you abuse alcohol?" 2. "Do you have any known cardiac disease?" 3. "Does your type of employment cause you to have exposure to chemicals?" 4. "Have you ever been told that you have had obstruction to your biliary ducts?" - 1 ~ Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts. The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension? 1. Flat neck veins 2. Abdominal distention 3. Hemoglobin of 14.2 g/dL (142 mmol/L) 4. Platelet count of 600,000 mm3 (600 × 109/L) - 2 ~ With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension). The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? (SATA) 1. Monitor daily weight. 2. Measure abdominal girth. 3. Monitor respiratory status. 4. Place the client in a supine position. 5. Assist the client with care as needed. - 1, 2, 3, 5 ~ Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites. The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1. Restlessness 2. Presence of asterixis 3. Complaints of fatigue 4. Decreased serum ammonia levels - 2 ~ Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted. The nurse should anticipate that the health care provider (HCP) will prescribe which treatment for a client with pernicious anemia? 1. Oral iron tablets 2. Blood transfusions 3. Gastric tube feedings 4. Vitamin B12 injections - 4 ~ A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem. Gastric tube feedings will not replace vitamin B12. Vitamin B12 needs to be given by injection to ensure absorption. A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record? 1. Apply a cold pack to the abdomen. 2. Administer 30 mL of milk of magnesia (MOM). 3. Maintain nothing by mouth (nil per os [NPO]) status. 4. Initiate an intravenous (IV) line for the administration of IV fluids. - 2 ~ Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery. A health care provider (HCP) prescribes a Salem sump tube for gastrointestinal intubation. Which item should the nurse obtain from the supply room? 1. A Dobbhoff weighted tube 2. A Sengstaken-Blakemore tube 3. A tube with a large lumen and an air vent 4. A tube with a single lumen that connects to suction - 3 ~ A tube with a large lumen and an air vent is a Salem sump tube. A Dobbhoff weighted tube is a type of feeding tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A tube with a single lumen is called a Levin tube. The nurse is caring for a client who is prescribed a nasogastric (NG) tube for the purpose of stomach decompression. The nurse should anticipate a health care provider prescription for which type of suction? 1. High and intermittent 2. Low and intermittent 3. High and continuous 4. Low and continuous - 2 ~ Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control. The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? 1. Rice 2. Corn 3. Broiled chicken 4. Cream of wheat - 2 ~ The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat. Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? 1. Decreased diarrhea 2. Decreased cramping 3. Improved intestinal tone 4. Elimination of peristalsis - 1 ~ Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication. Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? 1. "The medication will cause constipation." 2. "I need to take the medication with meals." 3. "I may have increased sensitivity to sunlight." 4. "This medication should be taken as prescribed." - 1 ~ Sulfasalazine is an anti-inflammatory sulfonamide. Constipation is not associated with this medication. It can cause photosensitivity, and the client should be instructed to avoid sun and ultraviolet light. It should be administered with meals, if possible, to prolong intestinal passage. The client needs to take the medication as prescribed and continue the full course of treatment even if symptoms are relieved. A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? (SATA) 1. Orthopnea and dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 4. Poor body posture and balance 5. Abdominal distention and tenderness - 1, 2, 3, 5 ~ Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure. A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? 1. Remove fluids from the meal tray. 2. Give the client 2 large meals per day. 3. Ask the client to sit up for 1 hour after eating. 4. Provide concentrated, high-carbohydrate foods. - 1 ~ Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying. The ambulatory care nurse is providing instructions to a client who is scheduled for a small bowel biopsy. What should the nurse tell the client? 1. Clear liquids only are allowed on the day of the test. 2. A signed informed consent form will need to be obtained. 3. A tube will be inserted through the rectum to obtain the tissue sample. 4. A full liquid diet will need to be maintained for 48 hours after the procedure. - 2 ~ A signed informed consent form is required for this procedure. The client is instructed to maintain a clear liquid diet for 24 to 48 hours before the biopsy and to withhold all food and fluids after the evening meal before the day of the scheduled biopsy. A small bowel biopsy involves removal of a tissue specimen from the small intestine for examination and aids in the diagnosis of diseases of the small intestine. A small biopsy tube is passed through the client's mouth and is monitored fluoroscopically until it reaches the desired location in the jejunum. A normal diet may be resumed after the procedure as soon as the gag reflex returns. The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action? 1. Document the findings. 2. Reassess the pH in 4 hours. 3. Instill 30 mL of sterile water. 4. Administer a dose of a prescribed antacid. - 4 ~ The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the health care provider should be notified. Documentation of the findings should be done after the administration of an antacid. Sterile water instillation is not an appropriate treatment. The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? 1. "I plan to eat 4 to 6 small meals a day." 2. "I should sleep in the right side-lying position." 3. "I plan to have a snack 1 hour before going to bed." 4. "I will stop having a glass of wine each evening with dinner." - 3 ~ The control of GERD involves lifestyle changes to promote health and control reflux. These include eating 4 to 6 small meals a day; avoiding alcohol and smoking; sleeping in the right side-lying position to promote oxygenation and frequent swallowing to clear the esophagus; and avoiding eating at least 3 hours before going to bed because reflux episodes are most damaging at night. The nurse is completing an admission assessment for a client with suspected esophageal cancer. Which statement made by the client indicates the presence of a risk factor for esophageal cancer? 1. "I've been smoking for 20 years now." 2. "I eat plenty of fresh fruits and vegetables." 3. "I'm 5 feet, 8 inches tall and weigh 160 pounds." 4. "My alcohol consumption is about 2 beers per month." - 1 ~ Primary risk factors associated with the development of esophageal cancer are smoking and obesity. The compounds in tobacco smoke may be responsible for the genetic mutations seen in many squamous cell carcinomas of the esophagus. Malnutrition, untreated gastroesophageal reflux disease (GERD), and excessive alcohol intake are also associated with esophageal cancer. Diets that are chronically deficient in fresh fruits and vegetables have also been implicated in the development of squamous cell carcinoma of the esophagus. The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? 1. "It's due to insufficient production of vitamin B12 in the colon." 2. "Increased production of intrinsic factor in the stomach leads to this type of anemia." 3. "Overproduction of vitamin B12 in the large intestine can result in pernicious anemia." 4. "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." - 4 ~ Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not produced or absorbed in the large intestine. A client with a diagnosis of stomach ulcer from gastric hyperacidity asks the nurse why the acid has not caused an ulcer in the small intestine as well. The nurse responds that the pH of intestinal contents is raised by bicarbonate, which is present in which area of the body? 1. Bile 2. Parietal cells 3. Liver enzymes 4. Pancreatic juice - 4 ~ Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. Bile, parietal cells, and liver enzymes are not substances rich in bicarbonate and are incorrect. A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? 1. Ileum 2. Cecum 3. Rectum 4. Jejunum - 2 ~ The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect. The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? (SATA) 1. Elevated lipase level 2. Elevated lactase level 3. Elevated trypsin level 4. Elevated amylase level 5. Elevated sucrase level - 1, 3, 4 ~ Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose. The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? 1. Colectomy 2. Appendectomy 3. Ascending colostomy 4. Small bowel resection - 4 ~ The small intestine is responsible for the absorption of most nutrients. The client who has undergone removal of a segment of the small bowel is the one who has a decreased area with which to absorb nutrients. Decreased absorption is not a likely complication with the surgical procedures identified in the remaining options. The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? 1. Sufficiently low water content in the stool 2. Low intestinal roughage that promotes easier digestion 3. Constriction of the anal sphincter based on voluntary control 4. Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord - 4 ~ The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes. The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client? 1. Low fat 2. High protein 3. High carbohydrate 4. Low in water-soluble vitamins - 1 ~ Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.