ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 44 : Introduction to the Gastrointestinal System and Accessory Structures Questions
Question 1 of 5
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
Question 2 of 5
The nurse is caring for a geriatric client at a long-term care facility. When administering the client's medications, which age-related change(s) of the client is anticipated? Select all that apply.
Correct Answer: B,C,E
Rationale: Age-related considerations when administering medications to a geriatric client include administering medications slowly and allowing time between medications due to a decreased motility in the esophagus. Additionally, the client has a weakened gag reflex, which may cause the client to choke. The client has a decreased elasticity of the rectal wall potentially causing fecal incontinence. Geriatric clients have a decrease in saliva production requiring water with oral medication administration. There is also a decrease in the amount of gastric secretions, which could produce nausea.
Question 3 of 5
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
Question 4 of 5
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
Correct Answer: C
Rationale: The nurse must assess the client's tolerance for pain and discomfort during the procedure. The nurse should assess the signs of perforation and the gag reflex after the procedure of EGD and not during the procedure. Assessing the client's level for retaining barium is important for a diagnostic test that involves the use of barium. EGD does not involve the use of barium.
Question 5 of 5
The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first?
Correct Answer: B
Rationale: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.