Digestive & Gastrointestinal System Disorders | NCLEX Quiz 73

1. A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Administer dilaudid

Notify the physician

Call and ask the operating room team to perform the surgery as soon as possible

Reposition the client and apply a heating pad on a warm setting to the client’s abdomen.

Based on the signs and symptoms presented in the question. the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice. although the physician probably would perform the surgery earlier than the prescheduled time.

Explanation

Based on the signs and symptoms presented in the question. the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice. although the physician probably would perform the surgery earlier than the prescheduled time.

2. The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery?

Intestinal obstruction

Fluid and electrolyte imbalance

Malabsorption of fat

Folate deficiency

A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

Explanation

A major complication that occurs most frequent following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

3. A client with ulcerative colitis has an order to begin salicylate medication to reduce inflammation. The nurse instructs the client to take the medication:

30 minutes before meals

On an empty stomach

After meals

On arising

Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken after meals to reduce GI irritation.

Explanation

Salicylate compounds act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. This medication needs to be taken after meals to reduce GI irritation.

4. During the assessment of a client's mouth. the nurse notes the absence of saliva. The client is also complaining of pain near the area of the ear. The client has been NPO for several days because of the insertion of a NG tube. Based on these findings. the nurse suspects that the client is developing which of the following mouth conditions?

Stomatitis

Oral candidiasis

Parotitis

Gingivitis

The lack of saliva. pain near the area of the ear. and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis. or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventative measures include the use of sugarless hard candy or gum to stimulate saliva production. adequate hydration. and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth.

Explanation

The lack of saliva. pain near the area of the ear. and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis. or inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventative measures include the use of sugarless hard candy or gum to stimulate saliva production. adequate hydration. and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth.

5. The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:

Severe and unrelenting. located in the epigastric area and radiating to the back.

Severe and unrelenting. located in the left lower quadrant and radiating to the groin.

Burning and aching. located in the epigastric area and radiating to the umbilicus.

Burning and aching. located in the left lower quadrant and radiating to the hip.

The pain associated with acute pancreatitis is often severe and unrelenting. is located in the epigastric region. and radiates to the back.

Explanation

The pain associated with acute pancreatitis is often severe and unrelenting. is located in the epigastric region. and radiates to the back.

6. When planning care for a client with ulcerative colitis who is experiencing symptoms. which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply.

Assessing the client’s bowel sounds

Providing skin care following bowel movements

Evaluating the client’s response to antidiarrheal medications

Maintaining intake and output records

Obtaining the client’s weight.

The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements. maintaining intake and output records. and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.

Explanation

The nurse can delegate the following basic care activities to the unlicensed assistant: providing skin care following bowel movements. maintaining intake and output records. and obtaining the client’s weight. Assessing the client’s bowel sounds and evaluating the client’s response to medication are registered nurse activities that cannot be delegated.

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7. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

“I will need to drain the pouch regularly with a catheter.”

“I will need to wear a drainage bag for the rest of my life.”

“The drainage from this type of ostomy will be formed.”

“I will be able to pass stool from my rectum eventually.”

A Kock pouch is a continent ileostomy. As the ileostomy begins to function. the client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucus drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

Explanation

A Kock pouch is a continent ileostomy. As the ileostomy begins to function. the client drains it every 3 to 4 hours and then decreases the draining to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucus drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure.

8. The client with a colostomy has an order for irrigation of the colostomy. The nurse used which solution for irrigation?

Distilled water

Tap water

Sterile water

Lactated Ringer’s

Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking. then bottled water should be used.

Explanation

Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking. then bottled water should be used.

9. The client with Crohn's disease has a nursing diagnosis of acute pain. The nurse would teach the client to avoid which of the following in managing this problem?

Lying supine with the legs straight

Massaging the abdomen

Using antispasmodic medication

Using relaxation techniques

The pain associated with Crohn’s disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques. applying local cold or heat to the abdomen. massaging the abdomen. and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen. which could aggravate the inflamed intestinal tissues as the abdominal muscles are stretched.

Explanation

The pain associated with Crohn’s disease is alleviated by the use of analgesics and antispasmodics and also is reduced by having the client practice relaxation techniques. applying local cold or heat to the abdomen. massaging the abdomen. and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen. which could aggravate the inflamed intestinal tissues as the abdominal muscles are stretched.

10. The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?

The stoma is slightly edematous

The stoma is dark red to purple

The stoma oozes a small amount of blood

The stoma does not expel stool

A stoma that appears dark red to purple may indicate compromised blood flow or ischemia, which is a serious condition that requires immediate medical attention. Slight edema and a small amount of blood are common in the initial post-op period, and the absence of stool can also be normal initially. However, a dark red to purple stoma suggests that the tissue may not be receiving adequate blood supply and should be reported to the physician immediately.

Explanation

A stoma that appears dark red to purple may indicate compromised blood flow or ischemia, which is a serious condition that requires immediate medical attention. Slight edema and a small amount of blood are common in the initial post-op period, and the absence of stool can also be normal initially. However, a dark red to purple stoma suggests that the tissue may not be receiving adequate blood supply and should be reported to the physician immediately.