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 working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
Correct Answer: A
Rationale: The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EG
D). The other options are lower gastrointestinal studies typically requiring a bowel preparation.
Question 2 of 5
The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
Correct Answer: B
Rationale: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EG
D). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
Question 3 of 5
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
Question 4 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 5 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.