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 patient who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery?
Correct Answer: C
Rationale: Adequate fluid intake is necessary to rid the GI tract of barium. The patient must not remain NPO after the test and enemas are not used to cleanse the bowel of barium. There is no need to avoid dairy products.
Question 2 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 3 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 4 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 5 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.