Test Bank Unit 8: Understanding Medical-Surgical Nursing
6th Edition Linda S. Williams Paula D. Hopper
Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function,
Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nurse is inspecting a patient’s oral cavity and notices reddened areas on the gums,
several teeth with cavities, and multiple loose teeth. Which finding is of greatest safety
concern to the nurse?
1. Reddened area on the gums can be a source of infection.
2. Dental cavities can be painful and a possible source of infection.
3. Loose teeth concern due to possible aspiration and airway blockage.
4. Abnormal findings in the oral cavity can lead to poor nutrition status.
ANS: 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 612
Heading: Oral Cavity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
Feedback
1 Reddened areas on the patient’s gums can be indicative of infection or
abscesses. The condition should be evaluated and treated by a dentist. This is
not the greatest safety concern.
2 Cavities can be a source of pain and infection. The condition should be
evaluated and treated by a dentist. This is not the greatest safety concern.
3 Loose teeth can be aspirated into the airway and become a choking risk or
airway blockage. This finding is the nurse’s greatest safety concern. The patient
needs to see a dentist as soon as possible.
4 It is true that abnormal oral cavity findings can interfere with the patient’s
nutritional status, but this is not the nurse’s greatest safety concern.
PTS: 1 CON: Health Promotion
2. The nurse is providing care for a patient whose nasogastric (NG) tube is attached to low
intermittent suction for decompression of a bowel obstruction. The nurse notes the NG tube
is not draining. After checking placement, which action should the nurse take?
1. Advance the NG tube 2 inches.
2. Change the suction setting to high.
3. Reinsert the NG tube into the other nares.
4. Irrigate the NG tube with 30 milliliters of normal saline.
ANS: 4
, Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for the insertion and maintenance of nasogastric tubes.
Page: 631
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The tube should not be advanced without a health care provider’s (HCP) order
unless it has migrated from the initial position. The question does not address
the possibility of this issue.
2 Suction should remain on a low setting to prevent damage to the lining of the
stomach.
3 The NG tube should not be pulled and reinserted without an HCP’s order.
There are a variety of methods to reestablish patency of the NG tube.
4 The nurse should irrigate the NG tube with 30 mL of normal saline to see if the
tube is blocked with secretions.
PTS: 1 CON: Patient-Centered Care
3. During the inspection of a patient’s abdomen, which data finding is most unlikely indicative
of a serious disorder?
1. Jaundice
2. Caput medusae
3. Visible mound
4. Silver-colored lines
ANS: 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 620
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Jaundice (icterus) is a yellowing of the skin and is usually associated with liver
dysfunction or disease.
2 Caput medusae is the appearance of a bluish-purple, swollen vein pattern
extending out from the navel. When found in an adult, it can be indicative of
portal hypertension or advanced alcoholic cirrhosis of the liver.
, 3 A visible mound noted with inspection of the abdomen can be indicative of a
tumor or other intra-abdominal issues.
4 Silver or thin red lines on the skin of the abdomen is the finding most unlikely
to indicate a serious disorder. Striae can develop during pregnancy or obesity
from stretching of the skin.
PTS: 1 CON: Patient-Centered Care
4. The nurse is auscultating the bowel sounds of a patient who is severely constipated and
exhibits a swollen abdomen and pain. Which bowel sounds cause the nurse to suspect a
bowel obstruction?
1. A series of soft clicks and gurgles
2. A complete absence of sounds
3. A high-pitched tinkling sound
4. A variety of nearly constant sounds
ANS: 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 659
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 A series of soft clicks and gurgles is considered to be normal bowel sounds.
2 A complete absence of bowel sounds may occur for a period following
anesthesia or indicate bowel disease.
3 A high-pitched tinkling sound is commonly associated with a bowel
obstruction especially if bowel sounds are absent distal to the area of
auscultation.
4 A variety of nearly constant bowel sounds is defined as hyperactive bowel
sounds and can occur for a variety of reasons.
PTS: 1 CON: Patient-Centered Care
5. The nurse is providing care for a patient who has just undergone a needle biopsy to rule out
liver disease. Which nursing intervention is most critical following the procedure?
1. Monitor vital signs every 4 hours.
2. Instruct to avoid coughing or straining.
3. Remain positioned on right side for 2 hours.
4. Medicate as needed for pain.
ANS: 3
, Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract.
Page: 628
Heading: Percutaneous Liver Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Vital signs will be monitored several hours as prescribed. Vital signs are
indicative of patient stability or instability following a procedure.
2 The patient will be instructed to avoid coughing or straining, exercise and
heavy lifting for a period of 1 week.
3 The most important nursing intervention following a percutaneous liver biopsy
is to keep the patient positioned on the right side for 2 hours to apply pressure
on the site and prevent bleeding. Risk for bleeding is associated with the
vascularity of the liver, and because liver disease can cause reduced clotting
ability.
4 The nurse will medicate the patient as needed for postprocedure pain; however,
this intervention is not as critical as monitoring for and preventing bleeding
from the biopsy site.
PTS: 1 CON: Patient-Centered Care
6. A patient is being prepared for an upper gastrointestinal (GI) series involving a barium
swallow. Which statement indicates that the patient understands the preparation for this test?
1. “I should eat a soft diet the night before the procedure.”
2. “I must not eat or drink for 4 hours after the procedure.”
3. “I’ll be given a clear liquid diet the night after the procedure.”
4. “I can’t have anything to eat or drink for 6 hours before the procedure.”
ANS: 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract.
Page: 627
Heading: Barium Swallow
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 It is not necessary for the patient to eat a soft diet the night before the test.
2 There is no reason to restrict oral intake following a barium swallow.
6th Edition Linda S. Williams Paula D. Hopper
Chapter 32. Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function,
Assessment, and Therapeutic Measures
MULTIPLE CHOICE
1. The nurse is inspecting a patient’s oral cavity and notices reddened areas on the gums,
several teeth with cavities, and multiple loose teeth. Which finding is of greatest safety
concern to the nurse?
1. Reddened area on the gums can be a source of infection.
2. Dental cavities can be painful and a possible source of infection.
3. Loose teeth concern due to possible aspiration and airway blockage.
4. Abnormal findings in the oral cavity can lead to poor nutrition status.
ANS: 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 612
Heading: Oral Cavity
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Health Promotion
Difficulty: Moderate
Feedback
1 Reddened areas on the patient’s gums can be indicative of infection or
abscesses. The condition should be evaluated and treated by a dentist. This is
not the greatest safety concern.
2 Cavities can be a source of pain and infection. The condition should be
evaluated and treated by a dentist. This is not the greatest safety concern.
3 Loose teeth can be aspirated into the airway and become a choking risk or
airway blockage. This finding is the nurse’s greatest safety concern. The patient
needs to see a dentist as soon as possible.
4 It is true that abnormal oral cavity findings can interfere with the patient’s
nutritional status, but this is not the nurse’s greatest safety concern.
PTS: 1 CON: Health Promotion
2. The nurse is providing care for a patient whose nasogastric (NG) tube is attached to low
intermittent suction for decompression of a bowel obstruction. The nurse notes the NG tube
is not draining. After checking placement, which action should the nurse take?
1. Advance the NG tube 2 inches.
2. Change the suction setting to high.
3. Reinsert the NG tube into the other nares.
4. Irrigate the NG tube with 30 milliliters of normal saline.
ANS: 4
, Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for the insertion and maintenance of nasogastric tubes.
Page: 631
Heading: Gastrointestinal Intubation
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 The tube should not be advanced without a health care provider’s (HCP) order
unless it has migrated from the initial position. The question does not address
the possibility of this issue.
2 Suction should remain on a low setting to prevent damage to the lining of the
stomach.
3 The NG tube should not be pulled and reinserted without an HCP’s order.
There are a variety of methods to reestablish patency of the NG tube.
4 The nurse should irrigate the NG tube with 30 mL of normal saline to see if the
tube is blocked with secretions.
PTS: 1 CON: Patient-Centered Care
3. During the inspection of a patient’s abdomen, which data finding is most unlikely indicative
of a serious disorder?
1. Jaundice
2. Caput medusae
3. Visible mound
4. Silver-colored lines
ANS: 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 620
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Physiological Adaptation
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Jaundice (icterus) is a yellowing of the skin and is usually associated with liver
dysfunction or disease.
2 Caput medusae is the appearance of a bluish-purple, swollen vein pattern
extending out from the navel. When found in an adult, it can be indicative of
portal hypertension or advanced alcoholic cirrhosis of the liver.
, 3 A visible mound noted with inspection of the abdomen can be indicative of a
tumor or other intra-abdominal issues.
4 Silver or thin red lines on the skin of the abdomen is the finding most unlikely
to indicate a serious disorder. Striae can develop during pregnancy or obesity
from stretching of the skin.
PTS: 1 CON: Patient-Centered Care
4. The nurse is auscultating the bowel sounds of a patient who is severely constipated and
exhibits a swollen abdomen and pain. Which bowel sounds cause the nurse to suspect a
bowel obstruction?
1. A series of soft clicks and gurgles
2. A complete absence of sounds
3. A high-pitched tinkling sound
4. A variety of nearly constant sounds
ANS: 3
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Differentiate normal and abnormal data collection findings.
Page: 659
Heading: Abdomen
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1 A series of soft clicks and gurgles is considered to be normal bowel sounds.
2 A complete absence of bowel sounds may occur for a period following
anesthesia or indicate bowel disease.
3 A high-pitched tinkling sound is commonly associated with a bowel
obstruction especially if bowel sounds are absent distal to the area of
auscultation.
4 A variety of nearly constant bowel sounds is defined as hyperactive bowel
sounds and can occur for a variety of reasons.
PTS: 1 CON: Patient-Centered Care
5. The nurse is providing care for a patient who has just undergone a needle biopsy to rule out
liver disease. Which nursing intervention is most critical following the procedure?
1. Monitor vital signs every 4 hours.
2. Instruct to avoid coughing or straining.
3. Remain positioned on right side for 2 hours.
4. Medicate as needed for pain.
ANS: 3
, Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract.
Page: 628
Heading: Percutaneous Liver Biopsy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 Vital signs will be monitored several hours as prescribed. Vital signs are
indicative of patient stability or instability following a procedure.
2 The patient will be instructed to avoid coughing or straining, exercise and
heavy lifting for a period of 1 week.
3 The most important nursing intervention following a percutaneous liver biopsy
is to keep the patient positioned on the right side for 2 hours to apply pressure
on the site and prevent bleeding. Risk for bleeding is associated with the
vascularity of the liver, and because liver disease can cause reduced clotting
ability.
4 The nurse will medicate the patient as needed for postprocedure pain; however,
this intervention is not as critical as monitoring for and preventing bleeding
from the biopsy site.
PTS: 1 CON: Patient-Centered Care
6. A patient is being prepared for an upper gastrointestinal (GI) series involving a barium
swallow. Which statement indicates that the patient understands the preparation for this test?
1. “I should eat a soft diet the night before the procedure.”
2. “I must not eat or drink for 4 hours after the procedure.”
3. “I’ll be given a clear liquid diet the night after the procedure.”
4. “I can’t have anything to eat or drink for 6 hours before the procedure.”
ANS: 4
Chapter: Chapter 32. Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Function Assessment, and Therapeutic Measures
Objective: Plan nursing care for patients having diagnostic tests of the gastrointestinal tract.
Page: 627
Heading: Barium Swallow
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity—Reduction of Risk Potential
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1 It is not necessary for the patient to eat a soft diet the night before the test.
2 There is no reason to restrict oral intake following a barium swallow.
