Nokea
The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first?
- A. Palpation
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
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The nurse is caring for a geriatric client at a long-term care facility. When administering the client's medications, which age-related change(s) of the client is anticipated? Select all that apply.
- A. Increased saliva causing drooling
- B. Decreased motility in the esophagus
- C. A weak gag reflex
- D. Increased amount of gastric secretions
- E. Decreased elasticity of the rectal wall
Correct Answer: B,C,E
Rationale: Age-related considerations when administering medications to a geriatric client include administering medications slowly and allowing time between medications due to a decreased motility in the esophagus. Additionally, the client has a weakened gag reflex, which may cause the client to choke. The client has a decreased elasticity of the rectal wall potentially causing fecal incontinence. Geriatric clients have a decrease in saliva production requiring water with oral medication administration. There is also a decrease in the amount of gastric secretions, which could produce nausea.
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studies. For which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
- A. Esophagogastroduodenoscopy
- B. Sigmoidoscopy
- C. Peritoneoscopy
- D. Colonoscopy
Correct Answer: A
Rationale: The nurse is correct to assess the gag reflex prior to offering fluids for a client having an esophagogastroduodenoscopy (EGD). The other options are lower gastrointestinal studies typically requiring a bowel preparation.
The instructor has just finished teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders. The instructor determines that the teaching was successful when the students identify which structure as possibly being affected?
- A. Liver
- B. Ileum
- C. Stomach
- D. Large Intestine
Correct Answer: C
Rationale: The upper gastrointestinal (GI) tract begins at the mouth and ends at the jejunum. Therefore, the stomach would be a component of the upper GI tract. The lower GI tract begins at the ileum and ends at the anus. The liver is considered an accessory structure.
The nurse is instructing the client on sensations commonly experienced when a contrast agent is injected into the body during diagnostic studies. Which sensation is most common?
- A. Light-headedness
- B. A warm sensation
- C. Heart palpitations
- D. Chills
Correct Answer: B
Rationale: The nurse informs the client of the potential to experience a warm sensation and nausea when the contrast agent is instilled. The client is instructed to take a couple of deep breaths, and, many times, the sensation will go away. The other options are not frequently encountered.
When assisting with preparing a client scheduled for a barium swallow, which instruction would be appropriate to include?
- A. Avoid smoking for at least 12 to 24 hours before the procedure.
- B. Take vitamin K before the procedure.
- C. Take three cleansing enemas before the procedure.
- D. Avoid the intake of red meat before the procedure.
Correct Answer: A
Rationale: The nurse should instruct the client to avoid smoking for at least a day before the procedure of barium swallow because smoking stimulates gastric motility. The client is advised to take vitamin K before a liver biopsy and instructed to take three cleansing enemas before a barium enema. Instruction to avoid red meat would be appropriate for a client who is having a Hemoccult test.