Nokea
The nurse working in the gastrointestinal clinic sees clients who are anemic. What are common causes for which the nurse assesses in these clients? (Select all that apply.)
- A. Colon cancer
- B. Diverticulitis
- C. Inflammatory bowel disease
- D. Peptic ulcer disease
- E. Pernicious anemia
Correct Answer: A,B,C,D
Rationale: In adults, the most common cause of anemia is GI bleeding. This is commonly associated with colon cancer, diverticulitis, inflammatory bowel disease, and peptic ulcer disease. Pernicious anemia is not associated with GI bleeding.
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The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
- A. Kidney
- B. Liver
- C. Spleen
- D. Stomach
Correct Answer: B
Rationale: Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting factors. The other organs are not directly related to this issue.
A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
- A. Auscultate the abdomen.
- B. Notify the provider immediately.
- C. Order an abdominal flat-plate x-ray.
- D. Palpate the abdomen to assess size.
Correct Answer: B
Rationale: The observation could indicate an abdominal aortic aneurysm, which could be life-threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated, but it is not the priority. Auscultation is part of the assessment, but the nurse's priority action is to notify the provider.
The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.)
- A. Decreased hydrochloric acid production
- B. Diminished nerve function in the large intestine
- C. Decreased fat digestion
- D. Decreased peristalsis in the large intestine
- E. Increased peristalsis in the large intestine
Correct Answer: A,B,C,D
Rationale: Several age-related changes occur in the gastrointestinal system. These include decreased hydrochloric acid production, diminished nerve function that leads to decreased sensation of the need to pass stool, decreased fat digestion, decreased peristalsis in the large intestine, and calcification of pancreatic vessels. Increased peristalsis is not an age-related change.
A client is having an esophagealgrosodendonescoropy (EGD) and has been given midazolam hydrochloride (Vessel). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?
- A. Administerin valoxone (Vessel).
- B. Call the Rapid Response Team.
- C. Provide physical stimulation.
- D. Ventilate with a bag-valre-mask.
Correct Answer: C
Rationale: For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after sedation is given, the nurse's first action is to provide physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam (Versed). The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
A client had a colossoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
- A. Come to the clinic immediately for evaluation.
- B. Monitor the bleeding and call back if it worsens.
- C. Take an over-the-counter stool softener.
- D. Avoid strenuous activity for a week.
Correct Answer: B
Rationale: A small amount of bright red blood on the toilet paper after a colonoscopy with biopsy is not uncommon due to minor irritation or trauma from the procedure. The nurse should advise the client to monitor the bleeding and call back if it worsens, as this could indicate a more serious issue. Immediate clinic evaluation is not necessary for a small spot of blood. Stool softeners or activity restrictions are not directly relevant unless specified by the provider.