Chapter 39: Nursing Assessment: Gastrointestinal System My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 39: Nursing Assessment: Gastrointestinal System

Test Bank

MULTIPLE CHOICE

1. The nurse is performing an assessment of an 80-year-old patient. Which information obtained by the nurse will be of most concern?

a.

Decreased appetite

b.

Difficulty chewing food

c.

Unintentional weight loss

d.

Complaints of indigestion

ANS: C

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.

DIF: Cognitive Level: Application REF: 903-906

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. To promote bowel evacuation in a patient with chronic complaints of constipation, the nurse will suggest that the patient 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.

ANS: B

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.

DIF: Cognitive Level: Application REF: 902-903

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. 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.

ANS: D

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.

DIF: Cognitive Level: Application REF: 901

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

a.

melena.

b.

steatorrhea.

c.

decreased serum cholesterol levels.

d.

increased serum indirect bilirubin levels.

ANS: B

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.

DIF: Cognitive Level: Application REF: 912 | 918

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. 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).

ANS: D

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 patients anxiety about discomfort.

DIF: Cognitive Level: Application REF: 913-916

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. 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?

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 (Tylenol) every 4 hours for chronic pain.

ANS: D

Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patients jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.

DIF: Cognitive Level: Application REF: 905-906

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. To palpate the liver, the nurse

a.

places one hand on the patients back and presses upward and inward with the other hand below the patients right costal margin.

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.

presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt.

d.

places one hand under the patients lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.

ANS: A

The liver is normally not palpable below the costal margin, the nurse needs to push inward below the right costal margin while lifting the patients back slightly with the left hand. The other methods will not allow palpation of the liver.

DIF: Cognitive Level: Application REF: 909-910

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

8. When the nurse is listening to a patients abdomen, which finding indicates a need for a focused abdominal assessment?

a.

Loud gurgles

b.

High-pitched gurgles

c.

Absent bowel sounds

d.

Frequent clicking sounds

ANS: C

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

DIF: Cognitive Level: Application REF: 909

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

a.

put pressure on the biopsy site using a sandbag.

b.

elevate the head of the bed to facilitate breathing.

c.

place the patient on the right side with the bed flat.

d.

check the patients postbiopsy coagulation studies.

ANS: C

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.

DIF: Cognitive Level: Application REF: 913-916

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. 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 has a permanent gastrostomy tube.

b.

The patient took a laxative the previous evening.

c.

The patient ate a low-fat bagel an hour previously.

d.

The patient had a high-fat meal the previous evening.

ANS: C

Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study.

DIF: Cognitive Level: Application REF: 913-916

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

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?

ANS: C

This question is the most open-ended and will provide the best overall information about the patients daily intake and risk for poor nutrition. The other questions may be asked, depending on the patients response to the first question.

DIF: Cognitive Level: Application REF: 906-907

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

12. 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 is very sleepy.

b.

The oral temperature is 101.6 F.

c.

The apical pulse is 104 beats/minute.

d.

The patient complains of a sore throat.

ANS: B

A temperature elevation may indicate that a perforation has occurred. The other assessment data are normal immediately after the procedure.

DIF: Cognitive Level: Application REF: 913-916

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

13. Which assessment finding in a patient 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

ANS: B

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.

DIF: Cognitive Level: Application REF: 908-911 | 913-916

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

14. 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?

a.

Offering the patient a glass of water

b.

Positioning the patient on the right side

c.

Checking the vital signs every 30 minutes

d.

Swabbing the patients mouth with cold water

ANS: A

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.

DIF: Cognitive Level: Application REF: 913-916

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

15. 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.

ANS: A

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

DIF: Cognitive Level: Application REF: 913-916

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Leave a Reply