ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 43 : Assessment of Digestive and Gastrointestinal Function Questions
Question 1 of 5
A nurse is caring for a newly admitted patient with a suspected GI bleed. The nurse assesses the patient's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?
Correct Answer: B
Rationale: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.
Question 2 of 5
A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
Correct Answer: B
Rationale: Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.
Question 3 of 5
An advanced practice nurse is assessing the size and density of a patient's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented?
Correct Answer: A
Rationale: Percussion is used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses. Percussion is used either independently or concurrently with palpation because it can validate palpation findings.
Question 4 of 5
A nurse is caring for a patient with biliary colic and is aware that the patient may experience referred abdominal pain. Where would the nurse most likely expect this patient to experience referred pain?
Correct Answer: B
Rationale: Patients with referred abdominal pain associated with biliary colic complain of pain below the right nipple. Referred pain above the left nipple may be associated with the heart. Groin pain may be referred pain from ureteral colic.
Question 5 of 5
An inpatient has returned to the medical unit after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding should the nurse report to the physician?
Correct Answer: D
Rationale: Barium has a high osmolarity and may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output (large stools). The barium will give the stools a milky white appearance, and it is not uncommon for the patient to experience an increase in the number of bowel movements. Blood in fecal matter is not an expected finding and the nurse should notify the physician.