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 caring for a client following a colonoscopy. During the procedure, two medium-sized polyps were removed. Which nursing assessment in the recovery area is a priority?
Correct Answer: C
Rationale: The nurse is correct in assessing vital signs following a colonoscopy with polyp removal as a priority. Vital signs of an increased pulse rate and falling blood pressure can indicate a perforation and bleeding. If a perforation occurs and is not addressed at an early stage, the client's level of consciousness can become affected. There would be no reliable stool present in the bowel to Hemoccult test due to the cleansing agent and potential bleeding from the polyp removal. The ability to tolerate fluids relates to the sedation process and is not as high of a priority.
Question 2 of 5
The nurse is examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract. Which would be the most important assessment for the nurse to make?
Correct Answer: B
Rationale: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.
Question 3 of 5
The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected?
Correct Answer: C
Rationale: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum.
Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.
Question 4 of 5
The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?
Correct Answer: B
Rationale: Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.
Question 5 of 5
The nurse is working with clients with digestive tract disorders. Which organ does the nurse realize has effects as an exocrine gland and an endocrine gland?
Correct Answer: B
Rationale: The pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.