Nokea
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.
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The nurse is caring for a client experiencing diarrhea. When teaching about the site in the body where water and electrolytes are absorbed, the nurse is most correct to instruct on which location?
- A. The small intestine
- B. The stomach
- C. The large intestine
- D. The cecum
Correct Answer: C
Rationale: The nurse is correct in instructing the client that water and electrolytes are mainly absorbed in the large intestine. The other options are not the best site for absorption.
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 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.
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.
Which nursing instruction is correct to provide the client following a barium enema?
- A. The client will maintain a low residue diet.
- B. The stools may be a white or clay colored.
- C. Sips of fluid may be increased if tolerated.
- D. An enema will be used to clear the bowel.
Correct Answer: B
Rationale: It is important to instruct the client that it is normal to have a white- or clay-colored stool following the barium enema. The client should report the color of the stool to the nurse. A progression of clay-colored stools to brown-colored stools should be noted. The client is prescribed a low-residue diet before the procedure. An increased fluid intake is offered to eliminate the barium from the bowel. The client is encouraged to move the bowel independently.