GI Questions With All Correct Answers
A client has a paracentesis during which 1500 mL of fluid is removed. The
nurse should monitor the client carefully for what reaction?
1
Hypertensive crisis
2
Hypovolemic shock
3
Abdominal distention
4
Tenting of the integument correct answer -Correct
Ans: 2
Fluid may shift from the intravascular space to the abdomen as fluid is
removed, leading to hypovolemia and compensatory tachycardia. Fluid shifts
can cause hypovolemia with resulting hypotension, not hypertension. A
paracentesis should decrease the degree of abdominal distention. Tenting of
the integument, a sign of dehydration, may occur. However, this assessment is
not as vital as assessing for signs of shock.
A high cleansing enema is prescribed for a client. What is the maximum height
at which the container of fluid should be held by the nurse when
administering this enema?
1
30 cm (12 inches)
2
37 cm (15 inches)
3
51 cm (20 inches)
4
66 cm (26 inches) correct answer -I put 1
Ans: 2
For a high colonic enema, the fluid must extend higher in the colon. If the
height of the enema fluid container above the anus is increased, the force and
rate of flow also increase. 30 cm (12 inches) is too low for a cleansing enema.
The heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may
cause mucosal injury.
,A client who had abdominal surgery asks the nurse about when the client can
return to work after discharge. Which is the most appropriate response by the
nurse?
1
"Not for at least two weeks."
2
"What type of work did you have in mind?"
3
"You can return to work soon if you know what it means to take it easy."
4
"You cannot return to work soon because you must get plenty of rest when
you get home." correct answer -Correct
Ans: 2
The nurse must identify the client's work activities before an appropriate
response can be made. The client probably can do light work that will not
injure the surgical site. The response "You can return to work if you know
what it means to take it easy" is vague and demeaning and gives little
direction to the client. Recovery from abdominal surgery usually takes more
than two weeks. While a client needs rest after abdominal surgery, this
response is premature depending upon what the nurse discovers during
further assessment.
A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple
procedure). The nurse expects that the client will have which tube after
surgery?
1
Chest
2
Intestinal
3
Nasogastric
4
Gastrostomy correct answer -Correct
Ans: 3
Nasogastric surgery involves the stomach, duodenum, pancreas, and common
bile duct; a nasogastric tube removes gastric secretions and prevents
distention of the gastrointestinal tract. A chest tube is used to remove air or
blood from the chest cavity; the chest is not entered in the Whipple procedure.
Intestinal tubes are used for small bowel obstructions; except for the
,duodenum, the small bowel is not included in the Whipple procedure. A
gastrostomy tube is used to deliver nutrients into the stomach of a client who
cannot ingest food via the oral route.
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of
bloody drainage from the client's nasogastric (NG) tube. Which action should
the nurse take?
1
Obtain vital signs
2
Clamp the NG tube
3
Instill 30 mL of iced normal saline into the NG tube
4
Record the observations and continue monitoring the client correct answer
-Correct
Ans: 1
Large amounts of blood or excessive bloody drainage 12 hours
postoperatively indicate that the client is hemorrhaging. Vital signs should be
taken. Clamping the tube is contraindicated; accumulation of secretions
causes pressure on the suture line, preventing further observation of
drainage. The primary healthcare provider must prescribe instilling 30 mL of
iced normal saline into the nasogastric tube. Continuing to monitor the
drainage and record the observations is an unsafe intervention at this time;
action must be taken to address and stop the hemorrhaging.
A nurse is caring for a client who is vomiting. When caring for this client, the
nurse considers the fact that the vomiting reflex follows a set pattern. List the
following steps in the order that they occur.
1.
Contraction of abdominal muscles
2.
Closure of the trachea to prevent aspiration
3.
Initiation of reverse peristalsis in the stomach
4.
Relaxation of the upper esophageal sphincter correct answer -Ans: 3, 1, 2,
4
, Reverse peristalsis starts the sequence; with contraction of the abdominal
muscles, gastric contents are propelled into the esophagus, and the upper
esophageal sphincter relaxes so vomiting can occur. Finally, the trachea closes
to prevent aspiration.
The nurse is caring for a client with biliary cancer. The associated jaundice
gets progressively worse. The nurse is most concerned about the potential
complication of what symptom?
1
Pruritus
2
Bleeding
3
Flatulence
4
Hypokalemia correct answer -Correct
Ans: 2
Obstruction of bile flow impairs absorption of phytonadione, a fat-soluble
vitamin; prothrombin is not produced, and the clotting process is prolonged.
Although deposition of bile salts in the skin may lead to pruritus, this is not
life threatening. Although there may be an increase in flatulence with biliary
disease, it is not life threatening. Obstructive jaundice does not affect
potassium levels.
A nurse is caring for a client with cholelithiasis and obstructive jaundice.
When assessing this client, the nurse should be alert for which findings that
are consistent with these conditions? Select all that apply.
1
Ecchymosis
2
Yellow sclera
3
Dark brown stool
4
Straw-colored urine
5
Pain in right upper quadrant correct answer -Correct
Ans: 1, 2, 5
A client has a paracentesis during which 1500 mL of fluid is removed. The
nurse should monitor the client carefully for what reaction?
1
Hypertensive crisis
2
Hypovolemic shock
3
Abdominal distention
4
Tenting of the integument correct answer -Correct
Ans: 2
Fluid may shift from the intravascular space to the abdomen as fluid is
removed, leading to hypovolemia and compensatory tachycardia. Fluid shifts
can cause hypovolemia with resulting hypotension, not hypertension. A
paracentesis should decrease the degree of abdominal distention. Tenting of
the integument, a sign of dehydration, may occur. However, this assessment is
not as vital as assessing for signs of shock.
A high cleansing enema is prescribed for a client. What is the maximum height
at which the container of fluid should be held by the nurse when
administering this enema?
1
30 cm (12 inches)
2
37 cm (15 inches)
3
51 cm (20 inches)
4
66 cm (26 inches) correct answer -I put 1
Ans: 2
For a high colonic enema, the fluid must extend higher in the colon. If the
height of the enema fluid container above the anus is increased, the force and
rate of flow also increase. 30 cm (12 inches) is too low for a cleansing enema.
The heights of 51 cm (20 inches) and 66 cm (26 inches) are too high and may
cause mucosal injury.
,A client who had abdominal surgery asks the nurse about when the client can
return to work after discharge. Which is the most appropriate response by the
nurse?
1
"Not for at least two weeks."
2
"What type of work did you have in mind?"
3
"You can return to work soon if you know what it means to take it easy."
4
"You cannot return to work soon because you must get plenty of rest when
you get home." correct answer -Correct
Ans: 2
The nurse must identify the client's work activities before an appropriate
response can be made. The client probably can do light work that will not
injure the surgical site. The response "You can return to work if you know
what it means to take it easy" is vague and demeaning and gives little
direction to the client. Recovery from abdominal surgery usually takes more
than two weeks. While a client needs rest after abdominal surgery, this
response is premature depending upon what the nurse discovers during
further assessment.
A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple
procedure). The nurse expects that the client will have which tube after
surgery?
1
Chest
2
Intestinal
3
Nasogastric
4
Gastrostomy correct answer -Correct
Ans: 3
Nasogastric surgery involves the stomach, duodenum, pancreas, and common
bile duct; a nasogastric tube removes gastric secretions and prevents
distention of the gastrointestinal tract. A chest tube is used to remove air or
blood from the chest cavity; the chest is not entered in the Whipple procedure.
Intestinal tubes are used for small bowel obstructions; except for the
,duodenum, the small bowel is not included in the Whipple procedure. A
gastrostomy tube is used to deliver nutrients into the stomach of a client who
cannot ingest food via the oral route.
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of
bloody drainage from the client's nasogastric (NG) tube. Which action should
the nurse take?
1
Obtain vital signs
2
Clamp the NG tube
3
Instill 30 mL of iced normal saline into the NG tube
4
Record the observations and continue monitoring the client correct answer
-Correct
Ans: 1
Large amounts of blood or excessive bloody drainage 12 hours
postoperatively indicate that the client is hemorrhaging. Vital signs should be
taken. Clamping the tube is contraindicated; accumulation of secretions
causes pressure on the suture line, preventing further observation of
drainage. The primary healthcare provider must prescribe instilling 30 mL of
iced normal saline into the nasogastric tube. Continuing to monitor the
drainage and record the observations is an unsafe intervention at this time;
action must be taken to address and stop the hemorrhaging.
A nurse is caring for a client who is vomiting. When caring for this client, the
nurse considers the fact that the vomiting reflex follows a set pattern. List the
following steps in the order that they occur.
1.
Contraction of abdominal muscles
2.
Closure of the trachea to prevent aspiration
3.
Initiation of reverse peristalsis in the stomach
4.
Relaxation of the upper esophageal sphincter correct answer -Ans: 3, 1, 2,
4
, Reverse peristalsis starts the sequence; with contraction of the abdominal
muscles, gastric contents are propelled into the esophagus, and the upper
esophageal sphincter relaxes so vomiting can occur. Finally, the trachea closes
to prevent aspiration.
The nurse is caring for a client with biliary cancer. The associated jaundice
gets progressively worse. The nurse is most concerned about the potential
complication of what symptom?
1
Pruritus
2
Bleeding
3
Flatulence
4
Hypokalemia correct answer -Correct
Ans: 2
Obstruction of bile flow impairs absorption of phytonadione, a fat-soluble
vitamin; prothrombin is not produced, and the clotting process is prolonged.
Although deposition of bile salts in the skin may lead to pruritus, this is not
life threatening. Although there may be an increase in flatulence with biliary
disease, it is not life threatening. Obstructive jaundice does not affect
potassium levels.
A nurse is caring for a client with cholelithiasis and obstructive jaundice.
When assessing this client, the nurse should be alert for which findings that
are consistent with these conditions? Select all that apply.
1
Ecchymosis
2
Yellow sclera
3
Dark brown stool
4
Straw-colored urine
5
Pain in right upper quadrant correct answer -Correct
Ans: 1, 2, 5
