Gastrointestinal System Nursing Exam Questions

Gastrointestinal System Nursing Exam Questions Related

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A client returns from surgery with a sigmoid colostomy. An ostomy appliance is attached. The priority nursing diagnosis for daily observation and care is:

  • A. Diarrhea related to alteration in bowel elimination.
  • B. Impaired skin integrity related to seepage.
  • C. Impaired nutrition: More than body requirements related to high-fat diet.
  • D. Impaired physical mobility related to surgical procedure.
Correct Answer: B

Rationale: The correct answer is B: Impaired skin integrity related to seepage. This is the priority nursing diagnosis because a colostomy appliance can lead to skin breakdown due to seepage of stool, which can cause irritation and skin breakdown. Maintaining skin integrity is crucial to prevent infection and promote healing.

A: Diarrhea is not the priority as it is a common issue after colostomy surgery but can be managed with appropriate interventions.

C: Impaired nutrition is not the priority as it is not specifically related to the immediate care of the colostomy appliance.

D: Impaired physical mobility is not the priority as it is not directly related to the immediate care of the colostomy appliance.

In summary, choice B is the correct answer because maintaining skin integrity is essential for the client's well-being and to prevent complications associated with a colostomy appliance.

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A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

  • A. Absence of nausea and vomiting.
  • B. Passage of mucus from the rectum.
  • C. Passage of flatus and feces from the colostomy.
  • D. Absence of stomach drainage for 24 hours.
Correct Answer: C

Rationale: The correct answer is C: Passage of flatus and feces from the colostomy. This indicates that the gastrointestinal tract is functioning properly post-operatively. The nasogastric tube is typically removed once the client's bowel function has returned, as evidenced by the passage of flatus and feces from the colostomy. This indicates that the client's bowels are working and there is no longer a need for the tube to decompress the stomach. Choices A, B, and D are incorrect because the absence of nausea and vomiting, passage of mucus from the rectum, and absence of stomach drainage do not directly indicate the return of normal bowel function, which is the key factor for removing the nasogastric tube in this scenario.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse makes which statement to the client?

  • A. Take a deep breath when I tell you and breathe normally while I remove the tube.
  • B. Take a deep breath when I tell you and bear down while I remove the tube.
  • C. Take a deep breath when I tell you and slowly exhale while I remove the tube.
  • D. Take a deep breath when I tell you and hold it while I remove the tube.
Correct Answer: C

Rationale: The correct answer is C because instructing the client to take a deep breath and slowly exhale while the tube is being removed helps relax the client's throat muscles, making the removal process smoother and less uncomfortable. Taking a deep breath and holding it (choice D) could lead to increased tension and resistance, while bearing down (choice B) may cause the client to push against the tube, making the removal difficult. Instructing the client to breathe normally (choice A) doesn't provide specific guidance on how to facilitate the removal process.

The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?

  • A. Carbohydrate
  • B. Protein
  • C. Fat
  • D. Water-soluble vitamins
Correct Answer: C

Rationale: The correct answer is C: Fat. In chronic pancreatitis, the pancreas struggles to produce digestive enzymes, leading to poor fat digestion. Limiting fat intake can help reduce symptoms like abdominal pain and diarrhea. Carbohydrates and proteins are essential for energy and tissue repair, so limiting them is not ideal. Water-soluble vitamins are generally well-absorbed and do not require restriction in chronic pancreatitis.

Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?

  • A. Profuse vomiting.
  • B. Cramping abdominal pain.
  • C. Abdominal distention.
  • D. High-pitched bowel sounds above the obstruction.
Correct Answer: A

Rationale: The correct answer is A: Profuse vomiting. In small bowel obstruction, the vomitus is typically profuse, as the small bowel is narrower and more distensible than the large bowel. This leads to rapid accumulation of gastric contents resulting in frequent vomiting. Cramping abdominal pain (B) can occur in both small and large bowel obstruction. Abdominal distention (C) is a common symptom in both types of obstruction due to the accumulation of gas and fluid. High-pitched bowel sounds above the obstruction (D) are indicative of partial obstruction and can be present in both small and large bowel obstruction.

Which of the following nursing measures would be inappropriate when caring for a client with a Cantor tube?

  • A. Injecting 10 mL of air into the tube to facilitate drainage.
  • B. Applying a water-soluble lubricant to the client's nares.
  • C. Coiling extra tubing on the client's bed.
  • D. Irrigating the tube with 50 mL of normal saline solution.
Correct Answer: D

Rationale: The correct answer is D because irrigating the Cantor tube with normal saline solution is inappropriate. Cantor tubes are typically used for gastric decompression or feeding, and irrigating with normal saline can disrupt the balance of electrolytes in the stomach. Choice A is correct as injecting air helps facilitate drainage. Choice B is correct as lubricant aids in tube insertion. Choice C is incorrect as coiling tubing can cause kinks and hinder drainage.

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