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Which of the following assessment findings in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider?
- A. Absent bowel sounds
- B. Scant nasogastric (NG) tube drainage
- C. Complaints of incisional pain
- D. Temperature 38.9°C (102°F)
Correct Answer: D
Rationale: An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.
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The nurse is assessing a patient who recently has been experiencing frequent 'heartburn' in the clinic. Which of the following information should the nurse include in the teaching plan?
- A. Barium swallow
- B. Radionuclide tests
- C. Endoscopy procedures
- D. Proton pump inhibitors
Correct Answer: D
Rationale: Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.
The nurse is admitting a patient who is vomiting bright red blood to the emergency department. Which of the following assessments should the nurse perform first?
- A. Checking the level of consciousness
- B. Measuring the quantity of any emesis
- C. Auscultating the chest for breath sounds
- D. Taking the blood pressure (BP) and pulse
Correct Answer: D
Rationale: The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.
Twelve hours after undergoing a gastroduodenostomy (Billroth II), a patient has symptoms of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. Which of the following actions should the nurse take next?
- A. Notify the surgeon.
- B. Irrigate the NG tube.
- C. Administer the prescribed morphine.
- D. Continue to monitor the NG drainage.
Correct Answer: A
Rationale: Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.
The nurse is caring for a patient with acute gastrointestinal (GI) bleeding who is receiving normal saline IV at a rate of 500 ml/hour. Which of the following findings obtained by the nurse is most important to communicate immediately to the health care provider?
- A. The patient's blood pressure (BP) has increased to 142/94 mm Hg.
- B. The nasogastric (NG) suction is returning coffee-ground material.
- C. The patient's lungs have crackles audible to the midline.
- D. The bowel sounds are very hyperactive in all four quadrants.
Correct Answer: C
Rationale: The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of the coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when the patient has GI bleeding.
The nurse is admitting a patient with a stroke who is unconscious and unresponsive, learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). Which of the following assessment parameters should the nurse plan to assess frequently?
- A. Bowel sounds
- B. Pupillary response
- C. Grip strength
- D. Oral mucosa
Correct Answer: D
Rationale: Due to the patient's unconscious state and history of GERD, frequent assessment of the oral mucosa is crucial to monitor for complications such as aspiration or mucosal damage from reflux. Bowel sounds, pupillary response, and grip strength are important but less directly related to GERD complications in this context.