Nokea
The nurse is preparing to measure the client's abdominal girth as part of the physical examination. At which location would the nurse most likely measure?
- A. In the right upper quadrant
- B. At the umbilicus
- C. At the lower border of the liver
- D. Just below the last rib
Correct Answer: B
Rationale: Measurement of abdominal girth is done at the widest point, which is usually the umbilicus. The right upper quadrant, lower border of the liver, or just below the last rib would be inappropriate sites for abdominal girth measurement.
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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.
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
- A. A complete blood count including differential
- B. Serum antibodies for H. pylori
- C. A sigmoidoscopy
- D. Gastric analysis
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
- A. Do you take an iron supplement on a daily basis?
- B. Does your diet include a moderate amount of vitamin C?
- C. Are you prescribed regular strength aspirin daily?
- D. Can you tell me the amount of alcohol that you drink on an average week?
- E. When was the last time that you included red meat in your diet?
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
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 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.