Deck 25: Alterations in Gastrointestinal Function

Question 1

An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant?
1) Risk for Aspiration Related to Regurgitation
2) Acute Pain Related to Esophageal Defect
3) Ineffective Infant Feeding Pattern Related to Uncoordinated Suck and Swallow
4) Ineffective Tissue Perfusion: Gastrointestinal, Related to Decreased Circulation

Answer 1

1

Question 2

A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment does the nurse ensure is prepared at the bedside?
1) Intubation setup
2) Appropriate bag and mask
3) Sterile gauze and saline
4) Soft arm restraints

Answer 2

1

Question 3

A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?
1) An infant with meningitis
2) A child with fever and neutropenia
3) Another child with gastroenteritis
4) A child recovering from an appendectomy

Answer 3

3

Question 4

The nurse is evaluating an infant's tolerance of feedings after a pyloromyotomy. Which finding indicates that the infant is not tolerating the feeding?
1) Need for frequent burping
2) Irritability during feeding
3) The passing of gas
4) Emesis after two feedings

Question 5

A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the client's plan of care?
1) Fowler's position 3 times per day for 30 minutes each time
2) Assist the child in choosing a low-fat diet.
3) Commode at bedside
4) Ambulate 3 to 4 times a day.

Question 6

A 3-day-old preterm infant is diagnosed with necrotizing enterocolitis. The nurse plans care around the frequent radiographs. How frequently should the nurse anticipate that the radiology staff will bring the portable machine to the nursery?
1) Every 6 hours
2) Every 12 hours
3) Every 24 hours
4) Every 48 hours

Question 7

The nurse is administering several medications to an infant with neurologic impairment and delay. Which medication is a proton pump inhibitor that is administered for gastroesophageal reflux?
1) Omeprazole
2) Ranitidine
3) Phenytoin
4) Glycopyrrolate

Question 8

A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborn's diagnosis?
1) Acute diarrhea; dehydration
2) Failure to pass meconium; abdominal distension
3) Currant jelly; gelatinous stools; pain
4) Projectile vomiting; altered electrolytes

Question 9

A child experienced a lacerated spleen in a motor vehicle accident. Which is the highest-priority nursing intervention on admission to the pediatric intensive care unit (PICU) following surgery?
1) Observing for signs of hypovolemic shock
2) Maintaining IV fluids
3) Implementing strict bedrest
4) Administering blood products as ordered

Question 10

The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents indicates appropriate understanding of the teaching session?
1) "We will change the colostomy bag with each wet diaper."
2) "We will use adhesive enhancers when we change the bag."
3) "We will watch for skin irritation around the stoma."
4) "We will expect a moderate amount of bleeding after cleansing the area around the stoma."

Question 11

The nurse is caring for a school-age client who had an appendectomy after a ruptured appendix. Which orders does the nurse anticipate for this client? Select all that apply.
1) Antibiotics
2) A clear liquid diet
3) NG tube
4) Vital signs every 4 hours
5) Frequent monitoring of bowel sounds

Question 12

The nurse is caring for a 5-month-old with biliary atresia. The mother asks why the healthcare provider wants her child to take the medication, cholestyramine. What would the nurse's response be?
1) Decrease itching
2) Increase WBCs
3) Decrease use of antibiotics
4) Increase appetite

Question 13

The nurse is preparing to ambulate a school-age client who had an appendectomy. In addition to pharmacological pain management, the nurse can use which nonpharmacological pain-management strategy for this client?
1) A heating pad
2) A warm, moist pack
3) A pillow on the abdomen
4) An ice pack

Question 14

An infant born with an omphalocele defect is admitted to the intensive-care nursery. Which instruction from the nurse manager to the unlicensed assistive personnel is most appropriate?
1) Prepare a warmer.
2) Prepare a crib.
3) Prepare a feeding of formula.
4) Prepare the bilirubin light.

Question 15

The nurse is caring for the newborn with hyperbilirubinemia. What nursing diagnoses would the nurse address? Select all that apply.
1) Activity intolerance
2) Deficient fluid volume
3) Risk for impaired attachment
4) Ineffective breathing pattern
5) Risk for imbalanced body temperature

Question 16

The nurse educator is preparing an in-service on the basic functions of the gastrointestinal (GI) system. Which statements will the nurse educator include in the in-service? Select all that apply.
1) "The GI system is responsible for the ingestion of fluids and nutrients."
2) "The GI system is responsible for the excretion of fluids and nutrients."
3) "The GI system is responsible for the metabolism of nutrients."
4) "As infants grow, their stomach capacity increases, decreasing the frequency with which they need to be fed."
5) "By the second year of life, digestive processes are still developing."

Question 17

The nurse is planning postoperative care for an infant after a cleft-lip repair. Which nursing intervention is most appropriate for this infant?
1) Prone positioning
2) Suctioning with a Yankauer device
3) Supine or side-lying positioning
4) Avoidance of soft elbow restraints

Question 18

A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate?
1) Withhold the feeding and notify the healthcare provider.
2) Replace the residual and continue with the full feeding.
3) Replace the residual but only give 5 mL of the feeding.
4) Withhold the feeding and check the residual in three hours.

Question 19

A child with inflammatory bowel disease is prescribed prednisone daily. At which time is it most appropriate for the family to administer the prednisone?
1) Between meals
2) One hour before meals
3) At bedtime
4) With meals