Nokea
The nurse is examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract. Which would be the most important assessment for the nurse to make?
- A. Checking if the skin is discolored
- B. Checking if the mucous membranes are dry
- C. Examining the sclera if it is yellow
- D. Observing for distended abdominal veins
Correct Answer: B
Rationale: Mucous membranes may be dry, and skin turgor may be poor in clients suffering from dehydration as a result of fluid losses from the GI tract. Checking the skin for discoloration and inspecting the sclera if it is yellow is taken into consideration when the client could have symptoms of jaundice, not fluid losses. Distended abdominal veins are not associated with dehydration.
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The nurse is caring for a client recovering from an esophagogastroduodenoscopy (EGD). Which of the following client symptoms would require further nursing assessment?
- A. Drowsiness
- B. Abdominal distention
- C. Sore throat
- D. Thirst
Correct Answer: B
Rationale: The nurse is correct to fully assess the client experiencing abdominal distention following an esophagogastroduodenoscopy (EGD). Abdominal distention could indicate complications such as perforation and bleeding. The client experiences drowsiness from the sedative during the early recovery process and a sore throat from passage of the scope. The client may also experience thirst because the client has not had liquids for a period of time.
The nurse is instructing a client prior to a colonoscopy. The client asks, 'Why do I have to drink this disgusting liquid?' The nurse is most correct to verbalize the goal of the oral preparation as which of the following?
- A. To allow ease of passage of the scope through the colon
- B. To decrease pain associated with fecal matter being pressed against the colon wall
- C. To cleanse the bowel to promote clear visualization of structures
- D. To eliminate gas from the internal portion of the colon
Correct Answer: C
Rationale: The goal of the oral preparation is to eliminate fecal matter to visualize the colon structures. Having a clean colon free of fecal matter does allow for ease of passage of the scope and eliminates gas. The client is sedated throughout the procedure so does not experience pain.
The nurse is caring for a client following gastrointestinal diagnostic testing. The client verbalizes feeling shame due to having frequent gas. Which nursing suggestion is best?
- A. Having gas following the procedure is normal. Expel the gas to decrease discomfort.
- B. Do not be ashamed. Everyone has gas following the procedure.
- C. The nursing staff is used to having clients with gas due to the procedure completed.
- D. Nurses anticipate that client will have gas following the procedure and provide privacy.
Correct Answer: A
Rationale: The nurse is correct to tell the client that this experience is normal and encourage the client to release the gas to decrease pain and discomfort. Providing information relieving the embarrassment and stating the benefit of the action is most helpful.
The nurse is working with clients with digestive tract disorders. Which organ does the nurse realize has effects as an exocrine gland and an endocrine gland?
- A. Gallbladder
- B. Pancreas
- C. Stomach
- D. Liver
Correct Answer: B
Rationale: The pancreas is both an exocrine gland, one that releases secretions into a duct or channel, and an endocrine gland, one that releases substances directly into the bloodstream. The other organs have a variety of functions but do not have a combination function such as the pancreas.
The nurse is providing community education at the mall. The nurse is instructing on the muscular tube that connects the mouth to the stomach. The nurse outlines this structure on a drawing and labels it with which of the following?
- A. Pharynx
- B. Pylorus
- C. Esophagus
- D. Ileum
Correct Answer: C
Rationale: The esophagus begins at the base of the pharynx and ends at the opening of the stomach. Layers of muscular tissue surround the esophagus. The pharynx is part of the throat situated immediately inferior to the mouth and nasal cavity. The pylorus is the region of the stomach that connects to the duodenum. The ileum is a portion of the small intestine.