Deck 41: Nursing Assessment: Gastrointestinal System
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Deck 41: Nursing Assessment: Gastrointestinal System
1
A patient is complaining of heartburn and a burning sensation in the epigastric area.What is a possible etiology for these complaints?
A) Cancer of the esophagus
B) Hiatal hernia
C) Peptic ulcer
D) GI infection
A) Cancer of the esophagus
B) Hiatal hernia
C) Peptic ulcer
D) GI infection
Hiatal hernia
2
A patient with an obstructed common bile duct has a T-tube placed in the common bile duct to drain bile produced by the liver.How much would the nurse expect the daily bile drainage to be?
A) 50 mL
B) 400 mL
C) 1000 mL
D) 2500 mL
A) 50 mL
B) 400 mL
C) 1000 mL
D) 2500 mL
1000 mL
3
When caring for a patient following a needle biopsy of the liver at the bedside,what should the nurse do?
A) Elevate the head of the bed to facilitate breathing.
B) Check the patient's postbiopsy coagulation studies.
C) Place the patient on the right side with the bed flat.
D) Instruct the patient to take shallow breaths to avoid pressure on the liver.
A) Elevate the head of the bed to facilitate breathing.
B) Check the patient's postbiopsy coagulation studies.
C) Place the patient on the right side with the bed flat.
D) Instruct the patient to take shallow breaths to avoid pressure on the liver.
Place the patient on the right side with the bed flat.
4
A patient returns to the nursing unit following an esophagogastroduodenoscopy (EGD).During postprocedure care,what is it most important for the nurse to do?
A) Position the patient on the right side.
B) Assess the patient's respiratory pattern.
C) Keep the patient on nothing by mouth (NPO)status until the gag reflex returns.
D) Provide mouth care with saline rinses and gargles.
A) Position the patient on the right side.
B) Assess the patient's respiratory pattern.
C) Keep the patient on nothing by mouth (NPO)status until the gag reflex returns.
D) Provide mouth care with saline rinses and gargles.
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5
Which following finding would the nurse expect to be present during auscultation of the abdomen of a patient with a bowel obstruction?
A) Decreased,low-pitched bowel sounds
B) Frequent clicking sounds
C) Absence of bowel sounds
D) Loud gurgles
A) Decreased,low-pitched bowel sounds
B) Frequent clicking sounds
C) Absence of bowel sounds
D) Loud gurgles
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6
Following an episode of vomiting bright red blood,a patient is hospitalized for evaluation.During physical assessment of the patient,which of the following findings does the nurse identify as abnormal?
A) Tympany on percussion of the abdomen
B) The liver edge 3 cm below the costal margin
C) Aortic pulsations visible in the epigastric area
D) Bowel sounds of 30 per minute in each quadrant
A) Tympany on percussion of the abdomen
B) The liver edge 3 cm below the costal margin
C) Aortic pulsations visible in the epigastric area
D) Bowel sounds of 30 per minute in each quadrant
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7
A healthy adult produces approximately how much saliva on a daily basis?
A) 500 mL
B) 1000 mL
C) 1500 mL
D) 2000 mL
A) 500 mL
B) 1000 mL
C) 1500 mL
D) 2000 mL
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8
Upon doing a physical assessment of a patient's gastrointestinal (GI)system,the nurse would expect to find the cecum and appendix in which quadrant?
A) Right upper quadrant
B) Left upper quadrant
C) Right lower quadrant
D) Left lower quadrant
A) Right upper quadrant
B) Left upper quadrant
C) Right lower quadrant
D) Left lower quadrant
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9
To promote bowel evacuation in a patient with irregular bowel elimination,what should the nurse teach the patient about how to initiate the gastrocolic and duodenocolic reflexes,to facilitate bowel elimination when the patient attempts defecation?
A) Try defecating after physical exercise.
B) Try defecating after the first daily meal.
C) Try defecating on arising in the morning.
D) Try defecating on seeing and smelling food.
A) Try defecating after physical exercise.
B) Try defecating after the first daily meal.
C) Try defecating on arising in the morning.
D) Try defecating on seeing and smelling food.
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10
A patient has an abnormally high serum ammonia level.Which of the following does the nurse recognize this finding to be indicative of?
A) A decreased bile flow into the intestine
B) A decrease in the number of bowel bacteria that deaminate amino acids
C) Failure of the liver to convert ammonia absorbed from the bowel to urea
D) An increased reabsorption of urobilinogen from the bowel into the blood
A) A decreased bile flow into the intestine
B) A decrease in the number of bowel bacteria that deaminate amino acids
C) Failure of the liver to convert ammonia absorbed from the bowel to urea
D) An increased reabsorption of urobilinogen from the bowel into the blood
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11
While obtaining a nursing history from a patient,which over-the-counter medication that the patient uses does the nurse recognize as being significant to liver disorders?
A) Aspirin
B) Antacids
C) Acetaminophen
D) Cough suppressants
A) Aspirin
B) Antacids
C) Acetaminophen
D) Cough suppressants
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12
Which of the following is an abnormal finding when performing an assessment of an 80-year-old patient?
A) Loss of appetite and anorexia
B) Difficulty chewing and swallowing food
C) Complaints of indigestion and stomach fullness
D) Consistent weight loss without change in dietary habits
A) Loss of appetite and anorexia
B) Difficulty chewing and swallowing food
C) Complaints of indigestion and stomach fullness
D) Consistent weight loss without change in dietary habits
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13
How should the nurse palpate the liver?
A) Press slowly and firmly over the right costal margin with one hand,and withdraw the fingers quickly after the liver edge is felt.
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) Place one hand on the patient's back,and press upward and inward with the other hand below the patient's right costal margin.
D) Place one hand under the patient's lower ribs,and press the left lower rib cage forward,palpating below the costal margin with the other hand.
A) Press slowly and firmly over the right costal margin with one hand,and withdraw the fingers quickly after the liver edge is felt.
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) Place one hand on the patient's back,and press upward and inward with the other hand below the patient's right costal margin.
D) Place one hand under the patient's lower ribs,and press the left lower rib cage forward,palpating below the costal margin with the other hand.
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14
Which major GI hormone is responsible for stimulating pancreatic bicarbonate secretion?
A) Gastrin
B) Secretin
C) Cholecystokinin
D) Gastric inhibitory peptide
A) Gastrin
B) Secretin
C) Cholecystokinin
D) Gastric inhibitory peptide
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15
A 68-year-old patient awakens at night with heartburn and belching.The nurse recognizes that these symptoms may occur when which of the following structures relaxes abnormally?
A) Epiglottis
B) Ileocecal valve
C) Pyloric sphincter
D) Lower esophageal sphincter (LES)
A) Epiglottis
B) Ileocecal valve
C) Pyloric sphincter
D) Lower esophageal sphincter (LES)
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16
Which one of the following is an age-related change in the GI system?
A) Increased sense of smell
B) Increased sensitivity of taste buds
C) Atrophy of gingival tissue
D) Increased motility of small intestine
A) Increased sense of smell
B) Increased sensitivity of taste buds
C) Atrophy of gingival tissue
D) Increased motility of small intestine
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17
The nurse documents the absence of bowel sounds in all quadrants of a patient's abdomen.How long should the nurse have auscultated the patient's abdomen?
A) 8 minutes
B) 10 minutes
C) 16 minutes
D) 20 minutes
A) 8 minutes
B) 10 minutes
C) 16 minutes
D) 20 minutes
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