Nokea
The nurse is providing care to a client who has had a percutaneous liver biopsy. For what would the nurse monitor the client?
- A. Signs and symptoms of bleeding
- B. Return of the gag reflex
- C. Passage of stool
- D. Intake and output
Correct Answer: A
Rationale: A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
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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 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.
A nurse is employed as a gastroenterologist's office nurse. When assessing the client, which objective data would provide useful information for diagnosis?
- A. Client verbalizing symptoms of nausea
- B. 22-lb weight loss in 2 months
- C. Client verbalizes chills and fatigue
- D. Client seated and stating pain
Correct Answer: B
Rationale: The best objective data with useful information is the fact that the client has lost 22 pounds in 2 months, indicating significant weight loss in a short period of time. This is data that, with further questioning, could provide further details for diagnosis. A client verbalizing symptoms of nausea and pain constitutes subjective data. Viewing the client's seated posture offers little data.
The nurse is preparing a client for magnetic resonance imaging (MRI) of the abdomen. Which statement by the client would indicate the need to notify the physician?
- A. I haven't had anything to eat or drink since midnight last night.
- B. I really don't like to be in small, enclosed spaces.
- C. I left all my jewelry and my watch at home.
- D. I will practice visualization to remain relaxed during the procedure.
Correct Answer: B
Rationale: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. Visualization will assist the client in relaxing during the procedure.
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.