Chapter 39- Patient Assessment- Gastrointestinal System My Nursing Test Banks

 

1.

A patient with severe ascites is scheduled for a paracentesis. Before the paracentesis, what is the most important nursing intervention?

A)

Assessing electrolyte and serum protein values

B)

Administering colon preparation medication

C)

Ensuring that the patients bladder is empty

D)

Shaving the patients abdomen

2.

A nurse is assisting a patient with Crohns disease who has just undergone surgery to remove part of her small intestine. The nurse notices blood in the stool of the patient. Which of the following should be included as part of the nurses responsibilities in caring for this patient? Select all that apply.

A)

Determining the origin of blood in the stool

B)

Performing emergency surgical repair of the small intestine

C)

Monitoring the patients blood pressure

D)

Administering parenteral nutrition for the patient

3.

The nurse is gathering information regarding the health history of a patient recently admitted to the critical care unit. Which pieces of information would the nurse need to update continually during this patients stay in the hospital? Select all that apply.

A)

Presence of bleeding

B)

Preexisting gastrointestinal conditions

C)

Nutritional status

D)

Previous abdominal surgeries

E)

Location of pain

F)

Family history of gastrointestinal conditions

4.

A nurse is performing an oral examination of a patient. Which of the following should she do as part of her examination?

A)

Palpate the temporomandibular joint for mobility.

B)

Leave the patients dentures in during the oral examination.

C)

Dim the lights to provide a calm environment for the patient.

D)

Recline the patient to the supine position.

5.

The nurse carefully assembles at the bedside the tools she needs for the oral examination of a patient who is on a ventilator. She then performs a thorough examination of the patients oral cavity, in compliance with her facilitys protocol. What is the best rationale for this nurses approach to examining the patients oral cavity?

A)

Prevention of cavities

B)

Elimination of halitosis

C)

Reduction in risk for ventilator-associated pneumonia

D)

Determination for the need for orthodontics

6.

A nurse is palpating a patients abdomen as part of the physical examination. The patient is suspected of having acute appendicitis. Which of the following would be an example of referred pain caused by the appendicitis?

A)

Rebound tenderness over the hypogastrium

B)

Dull pain from below the surface of the skin

C)

Pain on the surface of the skin

D)

Pain in the epigastric region of the abdomen, with no other apparent cause

7.

The nurse is examining the oral cavity of a patient. Which of the following findings should she be most concerned about?

A)

A pool of saliva under the tongue

B)

Symmetrical rising of soft palate and uvula when patient says ah

C)

Fruity breath odor

D)

Strong gag reflex

8.

A patient in the intensive care unit has abdominal cramping and is suspected of having a small intestine obstruction. Which finding on auscultation of the abdomen would tend to confirm this suspicion?

A)

High-pitched tinkling and rushing sounds

B)

High-pitched, rapid, and loud sounds

C)

Soft bubbling sounds with clicks and gurgles

D)

Absent bowel sounds

9.

A nurse is examining the anus and rectum of a patient. Which of the following findings would be of greatest concern to the nurse?

A)

The skin around the anus being darker than the surrounding area

B)

The finding of fecal impaction

C)

Even pressure being exerted by the anal sphincter

D)

Rectum walls being smooth, even, and uninterrupted

10.

A child with an undiagnosed gastrointestinal condition is malnourished. The nurse is monitoring and adjusting his parenteral nutrition as needed. What single evaluation is the most important for the nurse to perform to track this patients nutritional status?

A)

Height measurement

B)

Serial weight measurement

C)

Albumin level

D)

Visual inspection of skin

11.

A patients lab results are as follows: increased urobilingogen, albumin of 20 g/L (decreased from normal), globulin of 39 g/L (increased from normal), and transferrin of 198 mcg/dL (decreased from normal). Which gastrointestinal disorder do these results most strongly indicate?

A)

Cirrhosis

B)

Acute pancreatitis

C)

Ulcerative colitis

D)

Escherichia coli infection

12.

The nurse is caring for a critically ill patient and completes a gastrointestinal assessment every 4 hours. What is the best rationale for this nursing action?

A)

Part of routine care for all critically ill patients

B)

Ordered by the physician for this patient

C)

Satisfies the nurses curiosity

D)

Early identification of changes guides treatment decisions

13.

A patient is admitted for evaluation of right lower quadrant abdominal pain. The nurse hypothesizes that the pain may be related to disease of what?

A)

Sigmoid colon

B)

Duodenum

C)

Appendix

D)

Pancreas

14.

A patient with multiple trauma, including blunt trauma to the abdomen, is admitted to the critical care unit. The patient has unstable vital signs and is scheduled for immediate surgery. While completing the admission health history, what aspect would the nurse be most likely to defer until after the patient is stabilized?

A)

Allergies

B)

Diet preferences

C)

Quality of abdominal pain

D)

Location of abdominal pain

15.

While completing an admission examination on a critically ill patient, the nurse examines the patients oral cavity. What is the best rationale for this examination?

A)

Oral lesions can prevent adequate nutrition

B)

Part of routine admission assessment

C)

Appropriate only if the patient has facial trauma

D)

Can be done quickly

16.

The nurse is assessing a critically ill patients abdomen. What is the most appropriate order of this examination? Rank the answers from first to last.

A) Palpate over painful areas.

B) Inspect for bruising.

C) Auscultate bowel sounds.

D) Percuss border of liver.

17.

A patient is admitted after a motor vehicle crash resulting in blunt trauma to the abdomen. On initial examination, the nurse notices that the abdomen is bruised and slightly rounded, and the patient complains of abdominal pain. What is the most appropriate nursing action?

A)

Auscultate for bowel and vascular sounds.

B)

Measure abdominal girth at umbilicus.

C)

Reassess vital signs immediately.

D)

Elevate the head of the bed to 15 degrees.

18.

During examination of the abdomen, the nurse identifies an area of pain to light palpation in the right lower quadrant. What is the most appropriate next action?

A)

Deep palpation of the area

B)

Administering pain medication

C)

Assessing for rebound tenderness

D)

Auscultating for vascular sounds

19.

Laboratory test results in a critically ill patient include low prealbumin, low albumin, low total lymphocyte count, normal neutrophils, low sodium and chloride, and low hemoglobin and hematocrit. The patient has gained 10 pounds in the past 3 days. Prior to the weight gain, the patient was slightly underweight for height. Dietary intake before admission is not known. What is the best interpretation of this information?

A)

Blood loss

B)

Infection

C)

Malnutrition

D)

Fluid overload

20.

In a patient with severe parenchymal liver dysfunction, what laboratory test result does the nurse expect will be elevated?

A)

Serum albumin

B)

Transferrin

C)

Ammonia

D)

Cholesterol

Answer Key

1.

C

2.

A, C, D

3.

A, C, E

4.

A

5.

C

6.

D

7.

C

8.

A

9.

B

10.

B

11.

A

12.

D

13.

C

14.

B

15.

A

16.

B, C, D, A

17.

B

18.

C

19.

C

20.

C

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