Chapter 18: Gastrointestinal Alterations

Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously because the submucosa has no blood vessels.

ANS: B

The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer.

DIF: Cognitive Level: Remember/Knowledge REF: p. 480

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse is assessing the patient and notices that the oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient’s fluid intake has been sufficient. The nurses realizes that the condition of the patient’s mouth is probably caused by a. thoughts of food.

NURSINGTB.COM b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

ANS: B

Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.

DIF: Cognitive Level: Understand/Comprehension REF: p. 481

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

3. The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

ANS: A

Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease.

DIF: Cognitive Level: Apply/Application

REF: p. 495

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia.

4. The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following?

ANS: A

NURSINGTB.COM

Secretion of mucus by Brunner’s glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.

DIF: Cognitive Level: Apply/Application

REF: p. 482

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

5. After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that a. vitamin B12 is needed for the formation of red blood cells. b. vitamin B12 is needed to prevent a type of anemia. c. vitamin B12 is essential for surgical wound healing. d. vitamin B12 is always deficient in obese people.

ANS: A

Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Vitamin B12 is essential in the formation of red blood cells. A deficiency of B12 does lead to anemia, but this answer is not as specific as stating the relationship of B12 to red blood cells, so it is not as informative. Vitamins A and C are more essential for wound healing. Obese people may or may not be deficient in this vitamin.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 482

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

6. The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

ANS: C

Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).

DIF: Cognitive Level: Apply/Application

REF: p. 483

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

NURSINGTB.COM

MSC: NCLEX Client Needs Category: Physiological Integrity

7. The nurse is caring for a patient with liver disease. When assessing the patient’s laboratory values, the nurse should a. disregard the level of conjugated bilirubin. b. assess the total bilirubin c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

ANS: B

Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected in the indirect serum bilirubin level. In the liver, bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Cirrhosis and liver cancer decrease the liver’s ability to conjugate bilirubin. Some conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level. The direct or conjugated bilirubin is increased in liver failure. Total bilirubin is also measured and will also be increased in liver failure. There is no need to call the provider for values only slightly elevated. Unconjugated bilirubin is toxic to cells.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 484

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. The liver plays a major role in homeostasis by a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I.

ANS: C

The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and

X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovascular and microvascular.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 485

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

9. The liver detoxifies the blood by a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

ANS: A

Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This process is usually accomplished by conversion of the fat-soluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 485

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

10. The patient is being admitted to the hospital. At home, the patient takes an over-the-counter supplement of vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamin D is stored in the liver with a 10-month supply to prevent deficiency.

ANS: D

The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered, depending on the patient’s status.

DIF: Cognitive Level: Understand/Comprehension REF: p. 485

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucous membranes for signs of dryness. d. expect decreased bowel sounds.

ANS: B

Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.

DIF: Cognitive Level: Remember/Knowledge REF: p. 485

OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

12. In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack.

NURSINGTB.COM c. visceral pain often leads to tachycardia and hypertension. d. increasing intensity of pain is always significant.

ANS: D

Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distension, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distension, hemorrhage into tissue or the peritoneal space, or peritonitis.

DIF: Cognitive Level: Apply/Application REF: p. 489

OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath. d. watches for signs of pain and distension.

ANS: C

The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distension, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.

DIF: Cognitive Level: Remember/Knowledge

OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

14. When assessing the patient’s bowel sounds, the nurse a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patient’s knees.

ANS: C

REF: p. 490

NURSINGTB.COM

Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patient’s arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patient’s knees also helps to relax the abdominal wall.

DIF: Cognitive Level: Apply/Application

OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

15. When assessing bowel sounds, the nurse a. uses the “bell” part of the stethoscope. b. listens at least 15 minutes. c. expects bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting “absent bowel sounds.”

ANS: D

REF: p. 489

Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.

DIF: Cognitive Level: Remember/Knowledge REF: p. 489

OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Infection by Helicobacter pylori bacteria is a major cause of a. duodenal ulcers. b. Cushing’s ulcers. c. Curling’s ulcers. d. stress ulcers.

ANS: A

Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling’s ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing’s ulcers.

DIF: Cognitive Level: Remember/Knowledge REF: p. 490

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

17. The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to a. infection with Helicobacter pylori bacteria.

NURSINGTB.COM b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

ANS: D

A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow, leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 491

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

18. The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. it is not usually associated with alcohol intake or retching.

ANS: A

A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal anti-inflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

DIF: Cognitive Level: Understand/Comprehension REF: p. 491

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

19. The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: A

Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

DIF: Cognitive Level: Remember/Knowledge REF: p. 492

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient’s next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

ANS: A

GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground–like material is associated with upper GI bleeding. However, blood or coffee-ground–like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

DIF: Cognitive Level: Apply/Application REF: p. 492

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. All vital signs would expect to be normal. b. Oral temperature of 103°. c. Heart rate 125 beats per minute. d. Systolic blood pressure of 120 mm Hg.

21. The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss?

ANS: C

As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys. Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL 25% of the total blood volume.

DIF: Cognitive Level: Apply/Application

REF: p. 494 Clinical Alert Box

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

22. The patient is admitted with the diagnosis of GI bleeding. The patient’s heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: B

Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL 25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

DIF: Cognitive Level: Analyze/Analysis REF: p. 494 Clinical Alert Box

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

23. The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space, the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

ANS: C

The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

NURSINGTB.COM

DIF: Cognitive Level: Understand/Comprehension

REF: p. 494 Clinical Alert Box

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

24. The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%.

ANS: C

One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient’s intravascular volume status and whether the patient is actively bleeding.

DIF: Cognitive Level: Analyze/Analysis REF: p. 495

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

25. The patient is ordered to have large-volume gastric lavage. The nurse will most likely need to a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room-temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

ANS: D

Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room-temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

DIF: Cognitive Level: Apply/Application

REF: p. 495

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

26. The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that

NURSINGTB.COM a. bismuth will be added to the current triple therapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

ANS: A

Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 495

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

27. The nurse is to assist the provider in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-Fowler’s position.

ANS: B

Because endoscopy is performed at the patient’s bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.

DIF: Cognitive Level: Apply/Application

REF: p. 496

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

28. The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient’s abdomen is rigid. The nurse should a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid.

ANS: A

Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: p. 499 Clinical Alert Box

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

29. The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver’s collateral circulation.

ANS: B

Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver’s collateral circulation.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 498

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

30. The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must a. maintain as little traction as possible. b. apply external traction using a side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

ANS: D

It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: p. 300

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

31. The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumens and remove the tube. d. call the provider with an update of the patient’s condition.

ANS: C

Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible life-threatening complications that need to be assessed. Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, all three lumens are cut and the entire tube is removed. For this reason, scissors are kept at the patient’s bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.

DIF: Cognitive Level: Apply/Application

REF: p. 500

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

32. The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

ANS: D

Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 500

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

33. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, “What causes this? Why does it hurt so much?” The nurse should answer: a. “Pancreatitis is extremely rare, and no one knows why it causes pain.” b. “Pancreatitis is caused by diabetes; you should be checked.” c. “Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain.” d. “The pain is localized to the pancreas. Fortunately, it will not affect anything else.”

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ANS: C

The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 501

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Integrated Process: Teaching-Learning

MSC: NCLEX Client Needs Category: Physiological Integrity

34. The patient is admitted with acute pancreatitis. The nurse should a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D

The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

DIF: Cognitive Level: Apply/Application REF: p. 502

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

35. The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

ANS: B

Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient’s chance of significant morbidity and mortality. In Ranson’s research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

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DIF: Cognitive Level: Analyze/Analysis REF: Box 18-12

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

36. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. monitor the patient’s blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient’s fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

ANS: A

In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringer’s solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.

DIF: Cognitive Level: Apply/Application

REF: p. 510

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

37. The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient’s calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withholds any further calcium treatments. d. places an oral airway at the bedside.

ANS: A

Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low, and replacement of calcium is expected.

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DIF: Cognitive Level: Apply/Application

REF: p. 504

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

38. Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery.

ANS: D

Nasogastric suction and “nothing by mouth” status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distension, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. However, trends in nutritional management are changing. NPO status and NG suction are not used as much, especially for mild cased. Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.

DIF: Cognitive Level: Understand/Comprehension

REF: pp. 504-505 Evidence Based Practice Box

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

39. Pain control is a nursing priority in patients with acute pancreatitis because pain a. increases pancreatic secretions. b. is caused by decreased distension of the pancreatic capsule. c. decreases the patient’s metabolism. d. is caused by dilation of the biliary system.

ANS: A

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Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient’s metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 505

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

40. The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an “as needed” (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

ANS: D

Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

DIF: Cognitive Level: Apply/Application

REF: p. 505

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

41. The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

ANS: C

Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

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DIF: Cognitive Level: Understand/Comprehension REF: p. 506

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

42. The patient is diagnosed with hepatitis. In caring for this patient, the nurse should a. administer anti-inflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-the-counter anti-inflammatory medications at home.

ANS: B

No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

DIF: Cognitive Level: Apply/Application

REF: p. 507

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Jugular venous distension b. Normal sinus rhythm on the cardiac monitor c. Blood pressure of 180/90 mm Hg d. Stools that are guaiac positive

43. The nurse is caring for a critically ill patient with end-stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status?

ANS: A

Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases, and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

DIF: Cognitive Level: Analyze/Analysis REF: p. 509

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

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MSC: NCLEX Client Needs Category: Physiological Integrity

44. The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse’s first action should be to a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowler’s position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

ANS: B

Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler’s position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler’s position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

DIF: Cognitive Level: Apply/Application REF: p. 512

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

45. Lactulose is considered the first-line treatment for hepatic encephalopathy and works by a. causing ammonia to enter the bloodstream via the colon. b. trapping ammonia in the bowel for excretion. c. causing constipation and inhibiting the excretion of ammonia. d. creating an alkaline environment in the bowel.

ANS: B

Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.

DIF: Cognitive Level: Remember/Knowledge REF: p. 513

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

46. The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse a. evaluate renal function studies daily. b. give the medication every 12 hours. c. evaluate liver studies for signs of neomycin-induced damage. d. obtain stool guaiac tests to ensure that pathogens are being destroyed.

ANS: A

Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered.Guaiac tests are used to detect occult bleeding.

DIF: Cognitive Level: Apply/Application REF: p. 513

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

47. Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks.

ANS: C

Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.

DIF: Cognitive Level: Apply/Application REF: p. 513

OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.)

a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess

ANS: B, C, D

Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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REF: p. 490 a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. e. cholinergic drugs.

2. The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient’s care to prevent stress ulcers, the nurse would provide: (Select all that apply.)

ANS: B, C, D

Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

DIF: Cognitive Level: Apply/Application

REF: p. 491

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

3. When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.)

ANS: A, B, E

Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

DIF: Cognitive Level: Apply/Application

REF: p. 494 Clinical Alert Box

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

4. Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)

ANS: A, B, E

Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

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DIF: Cognitive Level: Apply/Application

REF: pp. 503-505

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation

5. The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)

ANS: B, C, E

Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.

DIF: Cognitive Level: Apply/Application

REF: Box 18-15

OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

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