Deck 39: Nursing Assessment: Gastrointestinal System

Question 1

When a patient has a history of a total gastrectomy, the nurse will monitor for clinical manifestations of

A) dehydration.
B) elevated total cholesterol.
C) cobalamin (vitamin BB₁₂) deficiency.
D) constipation.

Answer 1

cobalamin (vitamin BB₁₂) deficiency.

Question 2

While the nurse is obtaining a nursing history from a patient who is admitted with jaundice, the nurse will be most concerned about which patient statement?

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

Answer 2

"I use acetaminophen (Tylenol) every 4 hours for chronic pain."

Question 3

When the nurse is assessing an alert and independent older patient in the clinic for malnutrition risk, the most appropriate initial question is,

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

Answer 3

"Can you tell me the foods that you have eaten over the past 24 hours?"

Question 4

When caring for a patient following a needle biopsy of the liver at the bedside, the nurse should

A) elevate the head of the bed to facilitate breathing.
B) check the patient's post-biopsy coagulation studies.
C) place the patient on the right side with the bed flat.
D) put pressure on the biopsy site using a sandbag.

Question 5

To palpate the liver, the nurse

A) presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt.
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.
C) 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.
D) places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin.

Question 6

To promote bowel evacuation in a patient with irregular bowel elimination, the nurse teaches the patient that the effects of the gastrocolic and duodenocolic reflexes can facilitate bowel elimination if the patient attempts defecation

A) right after getting up in the morning.
B) immediately before the first daily meal.
C) after exercising.
D) after breakfast.

Question 7

The nurse is obtaining a nursing history from a patient with esophagitis and gastritis. A question that is appropriate for the nurse to ask during assessment of the patient's health perception-health management functional health pattern is,

A) "Do you smoke or use other forms of nicotine?"
B) "Did you have any pain associated with your vomiting?"
C) "What have you eaten in the last 24 hours?"
D) "Have you noticed any changes in your stools?"

Question 8

When listening to a patient's abdomen after the patient has eaten, the nurse will be concerned about

A) high-pitched gurgles.
B) frequent clicking sounds.
C) absent bowel sounds.
D) loud gurgles.

Question 9

During change of shift report, the nurse has just received all of this 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 refused to drink the ordered polyethylene glycol (GoLYTELY).
B) The patient has an allergic reaction to shellfish and iodine.
C) The patient has a permanent pacemaker to prevent bradycardia.
D) The patient is worried about discomfort during the examination.

Question 10

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?

A) The patient has no gag reflex.
B) The oral temperature is 100.6° F.
C) The patient complains of a sore throat.
D) The apical pulse is 104 beats/min.

Question 11

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. The nurse would expect daily bile drainage of _____ ml.

A) 50
B) 400
C) 1000
D) 2500

Question 12

The RN and NA are caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which nursing action being done by the NA requires that the RN intervene?

A) The NA positions the patient on the right side.
B) The NA checks the temperature every 30 minutes.
C) The NA offers the patient a glass of water.
D) The NA swabs the patient's mouth with cold water.

Question 13

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?

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

Question 14

The nurse will monitor a patient who has an obstruction of the common bile duct for

A) melena.
B) increased serum indirect bilirubin levels.
C) steatorrhea.
D) decreased serum cholesterol levels.

Question 15

When documenting the absence of bowel tones in all quadrants of a patient's abdomen, the nurse has auscultated the patient's abdomen for _____ minutes.

A) 8
B) 10
C) 16
D) 20

Question 16

A patient is hospitalized for evaluation after vomiting bright red blood. During a physical assessment of the patient, the nurse will be most concerned about

A) the liver edge 3 cm below the costal margin.
B) tympany on percussion of the abdomen.
C) aortic pulsations visible in the epigastric area.
D) bowel sounds of 30/minute in each quadrant.

Question 17

The nurse is performing an assessment of an 80-year-old patient. Information related to the patient's nutritional-metabolic functional health pattern that the nurse recognizes as abnormal in a patient of this age is

A) loss of appetite and anorexia.
B) difficulty chewing and swallowing food.
C) complaints of indigestion and fullness.
D) unintentional weight loss.