Question 1

A patient receiving tube feedings at 50 mL/hour has a residual volume of 250 mL of undigested tube feeding.What action should the nurse take?

Accepted Answer

As the residual amount is more than 100 mL or the amount specified by the agency or physician,the RN and the physician are notified,and the feeding will likely be stopped to prevent vomiting or aspiration.A.C.D.The nurse should not continue this tube feeding because of the risk of vomiting or aspiration.

Question 2

The nurse is collecting data from a patient who reports right upper abdominal quadrant warmth and tenderness.When the nurse touches the area lightly to assess for warmth and tenderness,what data collection technique is being used?

Accepted Answer

Light palpation uses touch and depresses the abdomen 0.5 to 1 inch.B.Inspection is looking at or observing an area.C.Percussion is using the hands and fingers to produce a sound that identifies the density of the organs beneath the area being percussed.D.Auscultation is the use of a stethoscope to listen for sounds.

Question 3

The nurse is ready to begin a tube feeding via an NG feeding tube for a patient who is comatose.What action should the nurse take before starting the feeding?

Accepted Answer

Prior to instilling anything into the NG tube,it is essential to verify placement of the NG tube; after x-ray is performed,the preferred method of verification is to check the pH of the gastric aspirate.A.Bowel sounds can be auscultated at any time.C.The NG tube should have been secured after insertion.D.The tube is irrigated with normal saline and not sterile water.

Question 4

The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes.How should the nurse document this finding?

Accepted Answer

Hypoactive bowel sounds are bowel sounds that are infrequent (normal is 5 to 30)over a 5-minute period and can occur in patients with a paralytic ileus or following abdominal surgery.A.Since the nurse heard sounds,absent bowel sounds would be incorrect to document.B.Normal bowel sounds occur 5 to 30 times over a 5 minute period.D.Hyperactive bowel sounds would be more than 30 sounds over a 5 minute period.

Question 5

A licensed practical nurse (LPN)who typically works on a medical unit has been assigned to cover staffing deficits on a surgical unit.After obtaining report,the nurse realizes that one of the assigned patients is currently receiving parenteral nutrition (PN).Which action should the nurse take?

Accepted Answer

Usually,registered nurses (RNs)are responsible for administering PN.Therefore,the LPN should discuss the assignment with the charge nurse and seek a possible adjustment.A.Providing patient care as assigned would be beyond the LPN's scope of practice.B.The LPN cannot make a patient care assignment change.C.The LPN needs to work through the charge nurse.

Question 6

A patient receiving a tube feeding at 60 mL/hr has a residual of 10 mL.What action should the nurse take?

Accepted Answer

If the residual amount is more than 100 mL or the amount specified by the agency or physician,the feeding should be stopped to prevent vomiting or aspiration and the physician notified.This feeding can be continued as ordered,as the residual amount is only 10 mL.B.C.D.The feeding does not need to be slowed,decreased,or held.

Question 7

The nurse is caring for a patient who is placed on a modified bland diet.Which should be removed before serving the patient's dinner tray?

Accepted Answer

Pepper,which is spicy,would not be included in a bland diet.A.B.D.These food items are bland.

Question 8

The nurse is preparing to initiate a tube feeding through a patient's nasogastric (NG)tube.Prior to initiating this feeding what should the nurse use to irrigate the tube?

Accepted Answer

Normal saline is used for NG tube irrigation to prevent loss of electrolytes.A.Sterile water could cause an electrolyte imbalance in the patient.C.D.Cranberry juice and carbonated water are not appropriate fluids to flush a nasogastric tube.

Question 9

The nurse is inspecting a patient's oral cavity.What is the most important safety reason for the nurse to inspect for loose teeth when collecting data on the oral cavity of a patient?

Accepted Answer

Loose teeth can be aspirated into the airway and become a choking risk.A.The nurse is not inspecting for loose teeth because it is unsightly to the patient.B.The nurse is not inspecting for loose teeth because of the risk for dental abscesses.D.Missing teeth is more likely to prevent a patient from eating.

Question 10

A patient is being prepared for an upper GI series.Which statement indicates that the patient understands the preparation for this test?

Accepted Answer

An appropriate patient diet preparation for an upper GI series is placing the patient on NPO restriction 6 to 8 hours before the procedure for best visualization.A.B.C.These statements indicate that the patient does not understand the correct way to prepare for this diagnostic test.

Question 11

The nurse is caring for a patient with cultural dietary needs.Which question should the nurse include in a cultural dietary assessment?

Accepted Answer

Understanding cultural influences,respecting them,and assisting the patient to maintain desired cultural practices are important for nutritional maintenance.Finding out which foods the patient likes will allow for planning to include those foods in meals.A.C.D.These questions do not necessarily assess the patient's cultural dietary preferences.

Question 12

The nurse is reinforcing teaching for a patient who is scheduled for an upper GI series.Which patient statement indicates teaching has been effective?

Accepted Answer

An upper GI is an x-ray of the esophagus,stomach,and duodenum using barium.A.B.C.These statements do not correctly explain an upper GI series.

Question 13

A patient receiving 70 mL of tube feeding per hour has a residual amount of 120 mL.What action should the nurse take?

Accepted Answer

If the residual amount is more than 100 mL or the amount specified by the agency or physician,the feeding should be stopped to prevent vomiting or aspiration and the physician notified.A.Slowing the feeding is not going to reduce the amount of residual.B.Continuing the feeding as ordered increases the patient's risk for aspiration or vomiting.C.Increasing the feeding will increase the patient's risk for aspiration or vomiting.

Question 14

The nurse is reviewing GI function with a patient.Which body structure should the nurse emphasize as accomplishing mechanical digestion in the stomach?

Accepted Answer

The stomach wall has three layers of smooth muscle that provide very efficient mechanical digestion to change food to a thick liquid called chyme.A.B.D.These structures do not perform mechanical digestion in the stomach.

Question 15

The nurse is caring for a patient whose NG tube,attached to low intermittent suction to decompress a bowel obstruction,is not draining.After checking placement,which action should the nurse take?

Accepted Answer

The nurse should irrigate the NG tube with 30 mL of normal saline to see if it is obstructed or on the stomach wall.B.Suction should remain on a low setting to prevent damage to the lining of the stomach.A.The tube should not be advanced without an HCP's order.C.The NG tube should not be pulled and reinserted without an HCP's order.

Question 16

The nurse is collecting data from a patient who is scheduled for an ileostomy.Which technique should the nurse use to help identify optimal stoma placement?

Accepted Answer

Inspection is observation.The abdomen is visually inspected to note the condition of the skin,the contour,belt line,and other factors that would affect optimal stoma placement.A.C.D.These techniques of data collection would not be appropriate when determining optimal placement for a stoma.

Question 17

The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose.Which action should the nurse take?

Accepted Answer

When feedings are administered,patients must be positioned in a sitting or high Fowler's position to reduce the risk of aspiration.A.B.D.These positions increase the patient's risk of aspiration.

Question 18

A 30-year-old patient with ulcerative colitis is scheduled for a proctosigmoidoscopy.Which finding should cause the nurse to clarify routine preparation orders with the physician?

Accepted Answer

Routine preparation with severe diarrhea can result in electrolyte imbalance.Bowel preparation may not be ordered for patients with bleeding or severe diarrhea.A.C.D.The patient's age,complaints of abdominal cramping,or current weight are not contraindications for the routine preparation for this diagnostic test.

Question 19

While providing care for a patient who has recently completed chemotherapy for colorectal cancer,the nurse notes the patient has an elevated carcinoembryonic antigen (CEA)level.How should the nurse interpret this test result?

Accepted Answer

CEA and carbohydrate antigen 19-9 are markers used to monitor gastrointestinal (GI)cancer treatment effectiveness and detect recurrence.A.An elevated level does not indicate that the patient is cured.C.An elevated CEA level would not be seen in the absence of disease and does not indicate liver function.D.Extremely low white blood cell counts would be used to determine if the patient needed to be placed in protective isolation.

Question 20

The nurse is reinforcing teaching provided to a patient with a peptic ulcer.Which patient statement indicates understanding about the function of hydrochloric acid in gastric juice?

Accepted Answer

Hydrochloric acid creates the pH of 1 to 2 that is necessary for pepsin to function and to kill most microorganisms that enter the stomach.A.B.D.These responses do not explain the function of hydrochloric acid in gastric juice.

Quiz 32: Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures