Question 1

The nurse is performing an assessment of an 80-year-old patient. Which information obtained by the nurse will be of most concern?&#10;A) Decreased appetite&#10;B) Difficulty chewing food&#10;C) Unintentional weight loss&#10;D) Complaints of indigestion

Accepted Answer

Unintentional weight loss is not a normal finding in older patients and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed, but are not of as much concern as the weight loss.

Question 2

To promote bowel evacuation in a patient with chronic complaints of constipation, the nurse will suggest that the patient should attempt defecation&#10;A) in the mid-afternoon.&#10;B) after eating breakfast.&#10;C) right after getting up in the morning.&#10;D) immediately before the first daily meal.

Accepted Answer

These reflexes are most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

Question 3

The health care provider sees a patient at 10 AM and writes an order for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which of these actions that are included in the agency policy for ERCP should the nurse take first?

A) Place the patient on NPO status.
B) Administer sedative medications.
C) Ensure the consent form is signed.
D) Explain the procedure to the patient.

Accepted Answer

The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.

Question 4

Which assessment finding in a patient who is being admitted to the hospital is most important to report to the health care provider?&#10;A) Tympany on percussion of the abdomen&#10;B) Liver edge 3 cm below the costal margin&#10;C) Bowel sounds of 20/minute in each quadrant&#10;D) Aortic pulsations visible in the epigastric area

Accepted Answer

Normally the lower border of the liver is not palpable below the ribs, so this finding suggests
hepatomegaly. The other findings are within normal range for the physical assessment.

Question 5

When a patient has a history of a total gastrectomy, the nurse will monitor for clinical manifestations of A) constipation. B) dehydration. C) elevated total cholesterol. D) cobalamin (vitamin B₁₂) deficiency.

Accepted Answer

The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B₁₂) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

Question 6

The nurse will monitor a patient who has an obstruction of the common bile duct for&#10;A) melena.&#10;B) steatorrhea.&#10;C) decreased serum cholesterol levels.&#10;D) increased serum indirect bilirubin levels.

Accepted Answer

A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.

Question 7

When the nurse is listening to a patient's abdomen, which finding indicates a need for a focused abdominal assessment?&#10;A) Loud gurgles&#10;B) High-pitched gurgles&#10;C) Absent bowel sounds&#10;D) Frequent clicking sounds

Accepted Answer

Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.

Question 8

Which action by nursing assistive personnel ( NAP ) when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy ( EGD ) requires that the RN intervene?&#10;A) Offering the patient a glass of water&#10;B) Positioning the patient on the right side&#10;C) Checking the vital signs every 30 minutes&#10;D) Swabbing the patient's mouth with cold water

Accepted Answer

Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the NAP are appropriate.

Question 9

During change-of-shift report, the nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure?

A) The patient has a permanent pacemaker to prevent bradycardia.
B) The patient is worried about discomfort during the examination.
C) The patient has had an allergic reaction to shellfish and iodine in the past.
D) The patient refused to drink the ordered polyethylene glycol (GoLYTELY).

Accepted Answer

If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure should be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient's anxiety about discomfort.

Question 10

When caring for a patient following a needle biopsy of the liver at the bedside, the nurse should&#10;A) put pressure on the biopsy site using a sandbag.&#10;B) elevate the head of the bed to facilitate breathing.&#10;C) place the patient on the right side with the bed flat.&#10;D) check the patient's postbiopsy coagulation studies.

Accepted Answer

After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site.

Question 11

When the nurse is obtaining a history from a patient who is admitted with jaundice, which statement is most indicative of a need for patient teaching?&#10;A) &#34;I used cough syrup several times a day last week.&#34;&#10;B) &#34;I take a baby aspirin every day to prevent strokes.&#34;&#10;C) &#34;I need to take an antacid for indigestion several times a week&#34;&#10;D) &#34;I use acetaminophen (Tylenol) every 4 hours for chronic pain.&#34;

Accepted Answer

The answer of When the nurse is obtaining a history...

Question 12

Which information obtained by the nurse when admitting a patient who is scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?&#10;A) The patient has a permanent gastrostomy tube.&#10;B) The patient took a laxative the previous evening.&#10;C) The patient ate a low-fat bagel an hour previously.&#10;D) The patient had a high-fat meal the previous evening.

Accepted Answer

The answer of Which information obtained by the nurse when...

Question 13

To palpate the liver, the nurse&#10;A) places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin.&#10;B) places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge.&#10;C) presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt.&#10;D) places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

Accepted Answer

The answer of To palpate the liver, the nurse&#10;A) places...

Question 14

When the nurse is assessing an alert and independent older patient in the clinic for malnutrition risk, the most appropriate initial question is,&#10;A) &#34;How do you get to the grocery store to buy your food?&#34;&#10;B) &#34;Do you have any difficulty in preparing or eating food?&#34;&#10;C) &#34;Can you tell me the foods that you have eaten over the past 24 hours?&#34;&#10;D) &#34;Are you taking any medications that alter your taste or tolerance of foods?&#34;

Accepted Answer

The answer of When the nurse is assessing an alert...

Question 15

Which information collected by the nurse when caring for a patient who has just arrived in the recovery area after an upper endoscopy is most important to communicate to the health care provider?&#10;A) The patient is very sleepy.&#10;B) The oral temperature is 101.6&#176; F.&#10;C) The apical pulse is 104 beats/minute.&#10;D) The patient complains of a sore throat.

Accepted Answer

The answer of Which information collected by the nurse when...

Deck 39: Nursing Assessment: Gastrointestinal System