Digestive & Gastrointestinal System Disorders | NCLEX Quiz 58

1. You're performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?

Observation. percussion. palpation. auscultation

Observation. auscultation. percussion. palpation

Percussion. palpation. auscultation. observation

Palpation. percussion. observation. auscultation

Observation. auscultation. percussion. palpation

Explanation

Observation. auscultation. percussion. palpation

2. You're preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

There is no need to change eating habits.

Eat six small meals a day.

Eat the largest meal in the evening.

Restrict fluid intake.

To avoid overloading the small intestine. encourage the patient to eat six small. regularly spaced meals.

Explanation

To avoid overloading the small intestine. encourage the patient to eat six small. regularly spaced meals.

3. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient's blood pressure because of which change that is associated with the liver failure?

Hypoalbuminemia

Increased capillary permeability

Abnormal peripheral vasodilation

Excess rennin release from the kidneys

Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure. so patients with liver failure require close blood pressure monitoring. Increased capillary permeability. abnormal peripheral vasodilation. and excess rennin released from the kidney’s aren’t direct ramifications of liver failure.

Explanation

Blood pressure decreases as the body is unable to maintain normal oncotic pressure with liver failure. so patients with liver failure require close blood pressure monitoring. Increased capillary permeability. abnormal peripheral vasodilation. and excess rennin released from the kidney’s aren’t direct ramifications of liver failure.

4. You're advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?

Peas

Cabbage

Broccoli

Yogurt

High-fiber foods stimulate peristalsis. and a result. flatus. Yogurt reduces gas formation.

Explanation

High-fiber foods stimulate peristalsis. and a result. flatus. Yogurt reduces gas formation.

5. You're assessing the stoma of a patient with a healthy. well-healed colostomy. You expect the stoma to appear:

Pale. pink and moist

Red and moist

Dark or purple colored

Dry and black

Good circulation causes tissues to be moist and red. so a healthy. well-healed stoma appears red and moist.

Explanation

Good circulation causes tissues to be moist and red. so a healthy. well-healed stoma appears red and moist.

6. You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

Formed

Semisolid

Semiliquid

Watery

A colostomy in the sigmoid colon produces a solid. formed stool.

Explanation

A colostomy in the sigmoid colon produces a solid. formed stool.

7. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you. "I know that I have colon cancer. too." Which response is most therapeutic?

“I know just how you feel.”

“You seem upset.”

“Oh. don’t worry about it. everything will be just fine.”

“Why do you think you have cancer?”

Making observations about what you see or hear is a useful therapeutic technique. This way. you acknowledge that you are interested in what the patient is saying and feeling.

Explanation

Making observations about what you see or hear is a useful therapeutic technique. This way. you acknowledge that you are interested in what the patient is saying and feeling.

8. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

To the exact size of the stoma.

About 1/16” larger than the stoma.

About 1/8” larger than the stoma.

About 1/4? larger than the stoma.

A proper fit protects the skin but doesn’t impair circulation. A 1/16” should be cut.

Explanation

A proper fit protects the skin but doesn’t impair circulation. A 1/16” should be cut.

9. You're doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

A reservoir is created that exits through the abdominal wall.

A second surgery is required 12 months after the first surgery.

A permanent ileostomy is created.

The surgery occurs in two stages.

An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3 months apart. First. diseased intestines are removed and a temporary loop ileostomy is created. Second. the loop ileostomy is closed and stool goes to the reservoir and out through the anus.

Explanation

An ileoanal reservoir is created in two stages. The two surgeries are about 2 to 3 months apart. First. diseased intestines are removed and a temporary loop ileostomy is created. Second. the loop ileostomy is closed and stool goes to the reservoir and out through the anus.

10. You're caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op. how much drainage can you expect from the ileostomy?

100 ml

500 ml

1500 ml

5000 ml

The large intestine absorbs large amounts of water so the initial output from the ileostomy may be as much as 1500 to 2000 ml/24 hours. Gradually. the small intestine absorbs more fluid and the output decreases.

Explanation

The large intestine absorbs large amounts of water so the initial output from the ileostomy may be as much as 1500 to 2000 ml/24 hours. Gradually. the small intestine absorbs more fluid and the output decreases.