Digestive & Gastrointestinal System Disorders | NCLEX Quiz 90

1. For Jayvin who is taking antacids. which instruction would be included in the teaching plan?

“Take the antacids with 8 oz of water.”

“Avoid taking other medications within 2 hours of this one.”

“Continue taking antacids even when pain subsides.”

“Weigh yourself daily when taking this medication.”

Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water. which dilutes the antacid. should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic. not an antacid.

Explanation

Antacids neutralize gastric acid and decrease the absorption of other medications. The client should be instructed to avoid taking other medications within 2 hours of the antacid. Water. which dilutes the antacid. should not be taken with antacid. A histamine receptor antagonist should be taken even when pain subsides. Daily weights are indicated if the client is taking a diuretic. not an antacid.

2. For Rico who has chronic pancreatitis. which nursing intervention would be most helpful?

Allowing liberalized fluid intake

Counseling to stop alcohol consumption

Encouraging daily exercise

Modifying dietary protein

Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.

Explanation

Chronic pancreatitis typically results from repeated episodes of acute pancreatitis. More than half of chronic pancreatitis cases are associated with alcoholism. Counseling to stop alcohol consumption would be the most helpful for the client. Dietary protein modification is not necessary for chronic pancreatitis. Daily exercise and liberalizing fluid intake would be helpful but not the most beneficial intervention.

3. When teaching a client about pancreatic function. the nurse understands that pancreatic lipase performs which function?

Transports fatty acids into the brush border

Breaks down fat into fatty acids and glycerol

Triggers cholecystokinin to contract the gallbladder

Breaks down protein into dipeptides and amino acids

Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin. not lipase.

Explanation

Lipase hydrolyses or breaks down fat into fatty acids and glycerol. Lipase is not involved with the transport of fatty acids into the brush border. Fat itself triggers cholecystokinin release. Protein breakdown into dipeptides and amino acids is the function of trypsin. not lipase.

4. Nurse Farrah is providing care for Kristoff who has jaundice. Which statement indicates that the nurse understands the rationale for instituting skin care measures for the client?

“Jaundice is associated with pressure ulcer formation.”

“Jaundice impairs urea production. which produces pruritus.”

“Jaundice produces pruritus due to impaired bile acid excretion.”

“Jaundice leads to decreased tissue perfusion and subsequent breakdown.”

Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired. increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However. edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.

Explanation

Jaundice is a symptom characterized by increased bilirubin concentration in the blood. Bile acid excretion is impaired. increasing the bile acids in the skin and causing pruritus. Jaundice is not associated with pressure ulcer formation. However. edema and hypoalbuminemia are. Jaundice itself does not impair urea production or lead to decreased tissue perfusion.

5. Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy?

Passage of two or three soft stools daily

Evidence of watery diarrhea

Daily deterioration in the client’s handwriting

Appearance of frothy. foul-smelling stools

Lactulose reduces serum ammonia levels by inducing catharsis. subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy. foul-smelling stools indicate steatorrhea. caused by impaired fat digestion.

Explanation

Lactulose reduces serum ammonia levels by inducing catharsis. subsequently decreasing colonic pH and inhibiting fecal flora from producing ammonia from urea. Ammonia is removed with the stool. Two or three soft stools daily indicate effectiveness of the drug. Watery diarrhea indicates overdose. Daily deterioration in the client’s handwriting indicates an increase in the ammonia level and worsening of hepatic encephalopathy. Frothy. foul-smelling stools indicate steatorrhea. caused by impaired fat digestion.

6. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client?

Administration of vasopressin and insertion of a balloon tamponade

Preparation for a paracentesis and administration of diuretics

Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction

Dietary plan of a low-fat diet and increased fluid intake to 2.000 ml/day

With acute pancreatitis. the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting. decrease painful abdominal distention. and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.

Explanation

With acute pancreatitis. the client is kept on nothing-by-mouth status to inhibit pancreatic stimulation and secretion of pancreatic enzymes. NG intubation with low intermittent suction is used to relieve nausea and vomiting. decrease painful abdominal distention. and remove hydrochloric acid. Vasopressin would be appropriate for a client diagnosed with bleeding esophageal varices. Paracentesis and diuretics would be appropriate for a client diagnosed with portal hypertension and ascites. A low-fat diet and increased fluid intake would further aggravate the pancreatitis.

7. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy. which nursing action would be most effective in ensuring safe care?

Measuring serum potassium for hyperkalemia

Assessing the client for hypervolemia

Measuring the client’s weight weekly

Documenting precise intake and output

For the client with ascites receiving diuretic therapy. careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses. which if not monitored closely and documented. could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia. not hyperkalemia. commonly occurs with diuretic therapy. Because urine output increases. a client should be assessed for hypovolemia. not hypervolemia. Weights are also an accurate indicator of fluid balance. However. for this client. weights should be obtained daily. not weekly.

Explanation

For the client with ascites receiving diuretic therapy. careful intake and output measurement is essential for safe diuretic therapy. Diuretics lead to fluid losses. which if not monitored closely and documented. could place the client at risk for serious fluid and electrolyte imbalances. Hypokalemia. not hyperkalemia. commonly occurs with diuretic therapy. Because urine output increases. a client should be assessed for hypovolemia. not hypervolemia. Weights are also an accurate indicator of fluid balance. However. for this client. weights should be obtained daily. not weekly.

8. Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?

Jaundice. dark urine. and steatorrhea

Acute right lower quadrant (RLQ) pain. diarrhea. and dehydration

Ecchymosis petechiae. and coffee-ground emesis

Nausea. vomiting. and anorexia

Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia. nausea. and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g.. Murphy’s sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis. petechiae. and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice. dark urine. and steatorrhea are clinical manifestations of the icteric phase of hepatitis.

Explanation

Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia. nausea. and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g.. Murphy’s sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis. petechiae. and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice. dark urine. and steatorrhea are clinical manifestations of the icteric phase of hepatitis.

9. Which phase of hepatitis would the nurse incur strict precautionary measures at?

Icteric

Non-icteric

Post-icteric

Pre-icteric

An esophageal tamponade tube would be inserted in critical situations. Typically. the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client’s cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client’s anxiety should be decreased. not maintained. and depending on the degree of hemorrhage. the client may not be alert.

Explanation

An esophageal tamponade tube would be inserted in critical situations. Typically. the client is fearful and highly anxious. The nurse therefore explains about the placement to help obtain the client’s cooperation and reduce his fear. This type of tube is used only short term and is not indicated for home use. The tube is large and uncomfortable. The client would not be helping to insert the tube. A client’s anxiety should be decreased. not maintained. and depending on the degree of hemorrhage. the client may not be alert.

10. Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.)

Assessing the client’s neurologic status every 2 hours

Monitoring the client’s hemoglobin and hematocrit levels

Evaluating the client’s serum ammonia level

Monitoring the client’s handwriting daily

Preparing to insert an esophageal tamponade tube

Making sure the client’s fingernails are short

Hepatic encephalopathy results from an increased ammonia level due to the liver‘s inability to covert ammonia to urea. which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client’s neurologic status. serum ammonia level. and handwriting. Monitoring the client’s hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.

Explanation

Hepatic encephalopathy results from an increased ammonia level due to the liver‘s inability to covert ammonia to urea. which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client’s neurologic status. serum ammonia level. and handwriting. Monitoring the client’s hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address jaundice.

Submit