Question 1

The nurse is reviewing gastrointestinal function. Mechanical digestion in the stomach is accomplished by which of these?

Accepted Answer

Mechanical digestion in the stomach is accomplished by the contraction of smooth muscle layers, which churn and mix food with gastric juice to form chyme. The mucosa and gastric glands secrete gastric juice, while the striated muscle layers are not present in the stomach.

Question 2

The nurse is checking tube feeding residual amounts and obtains 120 mL of residual. The patient is receiving 70 milliliter per hour of feeding. What action should the nurse take?

Accepted Answer

A residual amount of 120 mL indicates that the patient is not tolerating the feeding well, and there may be a risk for aspiration. Holding the feeding and notifying the physician is the safest action to take to prevent further complications.

Question 3

The nurse is collecting data for a patient who reports right upper abdominal quadrant warmth and tenderness. When the nurse touches the area lightly to assess for warmth and tenderness, what data collection technique is being used?

Accepted Answer

Palpation is the technique of using touch to gather data about an area, including assessing for warmth and tenderness. Auscultation is the technique of listening for sounds, inspection is the technique of visually examining the area, and percussion is the technique of tapping the area to assess for density or dullness.

Question 4

The nurse is assisting a patient who is scheduled for an ileostomy. Which of the following data collection techniques would the nurse use to help identify optimal stoma placement?

Accepted Answer

Inspection is the correct technique for identifying optimal stoma placement because it involves visually examining the abdomen to find the best location for the stoma, considering factors like skin folds, scars, and the waistline.

Question 5

The nurse is reinforcing teaching for a patient who has upper abdominal pain and is scheduled for an upper gastrointestinal (GI) series. Which of the following statements by the patient would indicate a correct understanding of the teaching?

Accepted Answer

An upper gastrointestinal (GI) series is an x-ray of the esophagus, stomach, and duodenum using barium. Choices A, B, and D describe different procedures that are not related to an upper GI series.

Question 6

The nurse is caring for a 30-year-old patient who has ulcerative colitis and is scheduled to have a proctosigmoidoscopy. Which of the following would cause the nurse to clarify routine preparation orders with the physician?

Accepted Answer

Severe diarrhea can affect the bowel preparation for the proctosigmoidoscopy and may require modification of the routine preparation orders.

Question 7

While providing care for a patient who has recently completed chemotherapy for colorectal cancer, the nurse notes the patient has an elevated carcinoembryonic antigen (CEA) level. Which of the following interpretations of this test result, by the nurse, is best?

Accepted Answer

Elevated CEA levels can indicate the presence of a residual or recurrent tumor in patients who have completed chemotherapy for colorectal cancer. It is important to further investigate this possibility and consult with the healthcare provider for appropriate treatment options.

Question 8

The nurse is checking tube feeding residual amounts and obtains 10 mL of residual. The patient is receiving 60 mL/hour of feeding. What action should the nurse take?

Accepted Answer

A residual amount of 10 mL is considered acceptable, and the feeding should be continued as ordered. A volume of greater than 200 mL or greater than 50% of the previous feeding should prompt further assessment and possible adjustment of feeding rate or formula. However, in this scenario, the residual amount is not significant enough to warrant any change or alarm.

Question 9

The nurse is caring for a patient whose nasogastric (NG) tube, attached to low intermittent suction to decompress a bowel obstruction, is not draining. After checking placement, which of these actions should the nurse take?

Accepted Answer

If the NG tube is not draining, irrigating the tube with 30 milliliters of normal saline can help clear any blockages in the tube. Changing the suction setting to high or advancing the NG tube 2 inches can cause injury or trauma to the patient's GI tract. Reinserting the NG tube in the other nare can be considered if other interventions have been unsuccessful, but only if the placement of the original NG tube has been verified.

Question 10

The nurse reinforces teaching for a patient who has been scheduled for an upper gastrointestinal (GI) series. Which of the following statements, by the patient, indicates teaching has been effective?

Accepted Answer

The correct statement that indicates effective teaching is "I can't have anything to eat or drink for 6 to 8 hours before the procedure." This is the correct preparation for an upper GI series as the patient needs an empty stomach for clear imaging. The other statements are incorrect as the patient should eat a regular diet the night before and can have a clear liquid diet after the procedure, but not the night of.

Question 11

The nurse is inspecting a patient's oral cavity. What is the most important safety reason to inspect for loose teeth when collecting data on the oral cavity of a patient?

Accepted Answer

Loose teeth can be aspirated into the airway, causing potential respiratory distress or even obstruction. This is a critical safety concern that necessitates checking for loose teeth when inspecting a patient's oral cavity.

Question 12

The nurse is reinforcing teaching for a patient who has a peptic ulcer. Which of the following statements by the patient would indicate a correct understanding of function of hydrochloric acid in gastric juice?

Accepted Answer

Hydrochloric acid in gastric juice functions to destroy pathogens, which helps protect the body from infection.

Question 13

The nurse is administering a tube feeding to a patient who has been receiving feedings at 50 mL/hour for 1 day. The nurse is checking placement and residual volume and is able to aspirate back 250 mL of undigested tube feeding. What action should the nurse take?

Accepted Answer

Aspirating 250 mL of undigested tube feeding is a significant amount and may indicate a problem with the patient's tolerance to the feeding. The nurse should report this to the RN for consultation with the physician to determine the appropriate course of action. Option A is not appropriate as the rate needs to be adjusted based on physician orders. Option B is not appropriate as aspirating a large amount of undigested feeding indicates a potential problem. Option D is not appropriate as waiting 2 hours before restarting the feeding is not necessary and may delay appropriate intervention.

Question 14

The nurse is caring for a patient who is placed on a modified bland diet. Which of the following should be removed before serving the patient's dinner tray?

Accepted Answer

Pepper is considered a spicy seasoning and should be removed from a modified bland diet. The other options (mayonnaise, salt, sugar) are not typically restricted on a modified bland diet.

Question 15

The nurse is ready to begin a tube feeding via a nasogastric (NG) feeding tube for a patient who is comatose. What is the priority action the nurse should take before starting the feeding?

Accepted Answer

Before starting tube feeding via NG tube, the nurse must check the pH of the gastric aspirate to ensure the tube is placed in the stomach and not the lungs. Incorrect placement of the tube into the lungs can lead to aspiration and respiratory complications. Securing the NG tube with additional tape, irrigating the tube with sterile water or listening to bowel sounds may be important before and after feeding, but not the priority action before starting the feed.

Question 16

The nurse is auscultating bowel sounds and hears two bowel sounds over 5 minutes. How should the nurse document this finding?

Accepted Answer

Bowel sounds occurring at a rate of less than 5 per minute are considered hypoactive. Hearing only two bowel sounds over 5 minutes indicates reduced intestinal activity, which is characteristic of hypoactive bowel sounds.

Question 17

Prior to initiating a tube feeding via nasogastric (NG) tube, the nurse irrigates the tube with which of the following?

Accepted Answer

Prior to initiating a tube feeding via nasogastric (NG) tube, the nurse irrigates the tube with normal saline to ensure that the tube is patent and free from any obstructions or residual formula. Cranberry juice, sterile water, and carbonated water are not appropriate for irrigation of an NG tube.

Question 18

The nurse is caring for a patient with cultural dietary needs. Which of the following questions should the nurse include in a cultural dietary assessment?

Accepted Answer

Asking "Which foods do you most commonly eat?" helps the nurse understand the patient's regular dietary habits and preferences, which is crucial for accommodating cultural dietary needs.

Question 19

An LPN who typically works on a medical unit has been pulled to cover staffing deficits on a surgical unit. After obtaining report, the nurse realizes that one of the assigned patients is currently receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Accepted Answer

As an LPN, the nurse is not trained to manage TPN, which is a specialty of registered nurses. Therefore, the LPN should notify the charge nurse that an adjustment in patient assignment is necessary to ensure safe and appropriate care for the patient receiving TPN.

Question 20

The nurse is ready to begin a tube feeding via a nasogastric feeding tube for a patient who is comatose. Which of the following actions should the nurse take?

Accepted Answer

Placing the patient in high Fowler's position will help prevent aspiration and promote digestion. The head of the bed should be elevated between 30-45 degrees. Choices A and C are incorrect because they can increase the risk of aspiration, and choice B is insufficient for preventing aspiration.

Quiz 32: Gastrointestinal, Hepatobiliary, and Pancreatic Systems Function, Assessment, and Therapeutic Measures