Nokea
The student nurse studying the gastrointestinal system understands that chyme refers to what?
- A. Hormenization that reduces acidity.
- B. Liquedied food ready for digestion
- C. Nutrients after being absorbed
- D. Secretions that help digest food
Correct Answer: B
Rationale: Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out so the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake into individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
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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.
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 is scheduled for a colonoscopy and the nurse has provided instructions on the bowel cleansing regimen. What statement by the client indicates a need for further teaching?
- A. Is a good thing I love oranges and cherry gelatin.
- B. My spouse will be here to drive me home.
- C. I should refrigerate the Gol/TELY before use.
- D. I will buy a case of Gonoxide before the prop.
Correct Answer: A
Rationale: The client should be advised to avoid beverages and gelatin that are red, orange, or purple in color as their residue can appear to be blood. The other statements show a good understanding of the preparation for the procedure.
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.
A client had an endoscopic retrograde cholangiopancreatography (ERCP). The nurse instructs the client and family about the signs of potential complications, which include what problems? (Select all that apply.)
- A. Cholangitis
- B. Pancreatitis
- C. Perforation
- D. Sepsis
- E. Kidney stones
Correct Answer: A,B,C,E
Rationale: Possible complications after an ERCP include cholangitis, pancreatitis, perforation, sepsis, and bleeding. Kidney stones are not a complication of ERCP.