Chapter 52: Assessment of the Gastrointestinal System

Chapter 52: Assessment of the Gastrointestinal System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The student nurse studying the gastrointestinal system understands that chyme refers to what?
   1. Hormones that reduce gastric acidity
   2. Liquefied food ready for digestion
   3. Nutrients after being absorbed
   4. Secretions that help digest food

ANS:   B

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 as the nutrients produced by digestion move from the lumen of the GI tract into the body’s circulatory system for uptake by individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.

DIF:     Remembering/Knowledge                 REF:    1085                 KEY: Gastrointestinal system             MSC:                                                  Integrated Process: Teaching/Learning NOT:             Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A client scheduled for a percutaneous transhepatic cholangiography (PTC) denies allergies to medication. What action by the nurse is best?
   1. Ask the client about shellfish allergies.
   2. Document this information on the chart.
   3. Ensure that the client has a ride home.
   4. Instruct the client on bowel preparation.

ANS:   A

PTC uses iodinated dye, so the client should be asked about seafood allergies, specifically to shellfish. Documentation should occur, but this is not the priority. The client will need a ride home afterward if the procedure is done on an outpatient basis. There is no bowel preparation for PTC.

DIF:     Applying/Application                         REF:    1093                 KEY: Gastrointestinal system| gastrointestinal assessment| allergies| nursing assessment MSC:     Integrated Process: Nursing Process: Assessment                                       NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride (Versed). The client’s respiratory rate is 8 breaths/min. What action by the nurse is best?
   1. Administer naloxone (Narcan).
   2. Call the Rapid Response Team.
   3. Provide physical stimulation.
   4. Ventilate with a bag-valve-mask.

ANS:           C

For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after the sedation is given, the nurse’s first action is to provide a physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for Versed. The Rapid Response Team is not needed at this point. The client does not need manual ventilation.

DIF:            Applying/Application                         REF:    1094                 KEY: Gastrointestinal system| medication side effects| nursing implementation MSC:   Integrated Process: Nursing Process: Implementation                                                      NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. 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?
   1. “It’s a good thing I love orange and cherry gelatin.”
   2. “My spouse will be here to drive me home.”
   3. “I should refrigerate the GoLYTELY before use.”
   4. “I will buy a case of Gatorade before the prep.”

ANS:           A

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.

DIF:            Evaluating/Synthesis                          REF:    1095                 KEY: Gastrointestinal system| gastrointestinal assessment| patient education MSC:        Integrated Process: Nursing Process: Evaluation                      NOT:                                                 Client Needs Category: Physiological Integrity: Reduction of Risk Potential