Nokea
A client is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
- A. Is a good thing I love oranges and cherry gelatin.
- B. My spouse will be here to drive me home.
- C. I should refrigerate the Gol/TELY before use.
- D. I will buy a case of Gonoxide before the prop.
Correct Answer: A
Rationale: The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
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The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
- A. Kidney
- B. Liver
- C. Spleen
- D. Stomach
Correct Answer: B
Rationale: Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting factors. The other organs are not directly related to this issue.
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?
- A. Colonoscopy.
- B. Enzyme-linked immunosorbent assay (ELISA) toxin A+B
- C. Ova and parasites
- D. Stool culture
Correct Answer: B
Rationale: Severe, watery diarrhea after antibiotic use may indicate Clostridioides difficile infection. The ELISA toxin A+B test is used to detect toxins produced by C. difficile. A colonoscopy, ova and parasites test, or stool culture are not typically warranted for this scenario unless further evaluation is needed.
The student nurse studying the gastrointestinal system understands that chyme refers to what?
- A. Hormenization that reduces acidity.
- B. Liquedied food ready for digestion
- C. Nutrients after being absorbed
- D. Secretions that help digest food
Correct Answer: B
Rationale: Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out so the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake into individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
- A. Colon cancer
- B. Diverticulitis
- C. Inflammatory bowel disease
- D. Peptic ulcer disease
- E. Pernicious anemia
Correct Answer: A,B,C,D
Rationale: In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?
- A. Ask the client about recent exposure to illness.
- B. Collect the stool sample for the client.
- C. Include the date and time on the specimen container.
- D. Don gloves prior to collecting the sample.
Correct Answer: D
Rationale: To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.