Deck 41: Nursing Assessment Gastro-intestinal System

Question 1

The nurse is caring for a client who has just had a colonoscopy. Which of the following symptoms should alert the nurse that a perforation has occurred? (Select all that apply.)

A)Malaise
B)Abdominal distension
C)Hypertension
D)Bradycardia
E)Tenesmus

Answer 1

Malaise
Abdominal distension
Tenesmus

Question 2

The nurse is caring for a client following a needle biopsy of the liver at the bedside. Which of the following actions should the nurse implement?

A)Put pressure on the biopsy site using a sandbag.
B)Elevate the head of the bed to facilitate breathing.
C)Place the client on the right side with the bed flat.
D)Check the client's postbiopsy coagulation studies.

Answer 2

Place the client on the right side with the bed flat.

Question 3

Which of the following actions by a nursing student when caring for a client who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene?

A)Offering the client a glass of water
B)Positioning the client on the right side
C)Checking the vital signs every 30 minutes
D)Swabbing the client's mouth with cold water

Answer 3

Offering the client a glass of water

Question 4

The nurse is listening to a client's abdomen. Which of the following findings indicate a need for a focused abdominal assessment?

A)Loud gurgles
B)High-pitched gurgles
C)Absent bowel sounds
D)Frequent clicking sounds

Question 5

The nurse is assessing an alert and independent older-adult client in the clinic for malnutrition risk. Which of the following questions is best as the initial assessment question?

A)"How do you get to the grocery store to buy your food?"
B)"Do you have any difficulty in preparing or eating food?"
C)"Can you tell me the foods that you have eaten over the past 24 hours?"
D)"Are you taking any medications that alter your taste or tolerance of foods?"

Question 6

The nurse is caring for a client who has an obstruction of the common bile duct. Which of the following findings should the nurse monitor in this client?

A)Melena
B)Steatorrhea
C)Decreased serum cholesterol levels
D)Increased serum indirect bilirubin levels

Question 7

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

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

Question 8

Which of the following information obtained by the nurse when admitting a client who is scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?

A)The client has a permanent gastrostomy tube.
B)The client took a laxative the previous evening.
C)The client ate a low-fat bagel an hour previously.
D)The client had a high-fat meal the previous evening.

Question 9

The nurse is caring for a client who has a history of a total gastrectomy. Which of the following clinical manifestations should the nurse monitor in the client?

A)Constipation
B)Dehydration
C)Elevated total cholesterol
D)Cobalamin deficiency

Question 10

The nurse is to promote bowel evacuation in a client with chronic complaints of constipation? Which of the following times should the nurse suggest that the client should attempt defecation?

A)In the mid-afternoon
B)After eating breakfast
C)Right after getting up in the morning
D)Immediately before the first daily meal

Question 11

The nurse is performing a nutritional assessment on a client. Which of the following information obtained by the nurse is of most concern?

A)Decreased appetite
B)Difficulty chewing food
C)Unintentional weight loss
D)Complaints of indigestion

Question 12

Which of the following information collected by the nurse when caring for a client who has just arrived in the recovery area after an esophagogastroduodenoscopy (EGD) is most important to communicate to the health care provider?

A)The client is very sleepy.
B)The oral temperature is 38.7°C (101.7°F).
C)The apical pulse is 104 beats/minute.
D)The client complains of a sore throat.

Question 13

The nurse is obtaining a history from a client who is admitted with jaundice. Which of the following statements is most indicative of a need for client teaching?

A)"I used cough syrup several times a day last week."
B)"I take a baby Aspirin every day to prevent strokes."
C)"I need to take an antacid for indigestion several times a week"
D)"I use acetaminophen every 4 hours for chronic pain."

Question 14

The health care provider sees a client at 10 A.M. and writes a prescription for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which of the following actions that are included in the agency protocol for ERCP should the nursetake first?

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

Question 15

The nurse is preparing to assess a client's liver. When palpating the liver, which of the following techniques should the nurse implement?

A)Place one hand on the client's back and press upward and inward with the other hand below the client's right costal margin.
B)Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge.
C)Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt.
D)Place one hand under the client's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.

Question 16

Which of the following assessment findings in a client who is being admitted to the hospital is most important to report to the health care provider?

A)Tympany on percussion of the abdomen
B)Liver edge 3 cm below the costal margin
C)Bowel sounds of 20/minute in each quadrant
D)Aortic pulsations visible in the epigastric area