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Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 39: Nursing Assessment: Gastrointestinal System
MULTIPLE CHOICE
1. The nurse is performing an assessment of an 80-year-old patient. Information related to the
patient’s nutritional-metabolic functional health pattern that the nurse recognizes as abnormal
in a patient of this age is
a. loss of appetite and anorexia.
b. difficulty chewing and swallowing food.
c. complaints of indigestion and fullness.
d. unintentional weight loss.
Correct Answer: D
Rationale: Unintentional weight loss is not a normal finding in older patients and may indicate a
problem such as cancer or depression. Poor appetite, difficulty in chewing and swallowing, and
complaints of indigestion are common in older patients.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 933
NCLEX: Physiological Integrity
2. To promote bowel evacuation in a patient with irregular bowel elimination, the nurse teaches
the patient that the effects of the gastrocolic and duodenocolic reflexes can facilitate bowel
elimination if the patient attempts defecation
a. right after getting up in the morning.
b. immediately before the first daily meal.
c. after exercising.
d. after breakfast.
Correct Answer: D
Rationale: These reflexes are most active after the first daily meal. Arising in the morning, the
anticipation of eating, and physical exercise do not stimulate these reflexes.
Cognitive Level: Application
Nursing Process: Implementation
Text Reference: p. 930
NCLEX: Physiological Integrity
3. When a patient has a history of a total gastrectomy, the nurse will monitor for clinical
manifestations of
a. dehydration.
b. elevated total cholesterol.
c. cobalamin (vitamin B12) deficiency.
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Test Bank
39-2
d. constipation.
Correct Answer: C
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor, which is needed
for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of
water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or
constipation.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 929
NCLEX: Physiological Integrity
4. A patient with an obstructed common bile duct has a T-tube placed in the common bile duct
to drain bile produced by the liver. The nurse would expect daily bile drainage of _____ ml.
a. 50
b. 400
c. 1000
d. 2500
Correct Answer: C
Rationale: The normal excretion of bile by the liver is about 1 L daily.
Cognitive Level: Application
Nursing Process: Assessment
5.
a.
b.
c.
d.
Text Reference: p. 932
NCLEX: Physiological Integrity
The nurse will monitor a patient who has an obstruction of the common bile duct for
melena.
increased serum indirect bilirubin levels.
steatorrhea.
decreased serum cholesterol levels.
Correct Answer: C
Rationale: A common bile duct obstruction will reduce the absorption of fat in the small
intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile
duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin
level is increased with biliary obstruction.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 940
NCLEX: Physiological Integrity
6. Which information collected by the nurse when caring for a patient who has just arrived in
the recovery area after an upper endoscopy is most important to communicate to the health
care provider?
a. The patient has no gag reflex.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
39-3
b. The oral temperature is 100.6° F.
c. The patient complains of a sore throat.
d. The apical pulse is 104 beats/min.
Correct Answer: B
Rationale: A temperature elevation may indicate that a perforation has occurred. The other
assessment data are normal immediately after the procedure.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 943
NCLEX: Physiological Integrity
7. During change of shift report, the nurse has just received all of this information about a
patient who is scheduled for a colonoscopy. Which information should be communicated to
the health care provider before sending the patient for the procedure?
a. The patient refused to drink the ordered polyethylene glycol (GoLYTELY).
b. The patient has an allergic reaction to shellfish and iodine.
c. The patient has a permanent pacemaker to prevent bradycardia.
d. The patient is worried about discomfort during the examination.
Correct Answer: A
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be visualized
and the procedure should be rescheduled. Because contrast solution is not used during
colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic
resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the patient about the
sedation used during the examination to decrease the patient’s anxiety about discomfort.
Cognitive Level: Application
Text Reference: p. 943
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
8. A patient is hospitalized for evaluation after vomiting bright red blood. During a physical
assessment of the patient, the nurse will be most concerned about
a. the liver edge 3 cm below the costal margin.
b. tympany on percussion of the abdomen.
c. aortic pulsations visible in the epigastric area.
d. bowel sounds of 30/minute in each quadrant.
Correct Answer: A
Rationale: Normally the lower border of the liver is not palpable below the ribs, so this finding
suggests hepatomegaly. The other findings are within normal range for the physical assessment.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 940
NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
39-4
9. The RN and NA are caring for a patient who has just returned to the nursing unit after an
esophagogastroduodenoscopy (EGD). Which nursing action being done by the NA requires
that the RN intervene?
a. The NA positions the patient on the right side.
b. The NA checks the temperature every 30 minutes.
c. The NA offers the patient a glass of water.
d. The NA swabs the patient’s mouth with cold water.
Correct Answer: C
Rationale: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for
aspiration. The other actions by the NA are appropriate.
Cognitive Level: Application
Text Reference: p. 943
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
10. While the nurse is obtaining a nursing history from a patient who is admitted with jaundice,
the nurse will be most concerned about which patient statement?
a. “I take a baby aspirin every day to prevent strokes.”
b. “I need to take an antacid for indigestion several times a week”
c. “I use acetaminophen (Tylenol) every 4 hours for chronic pain.”
d. “I used cough syrup several times a day last week.”
Correct Answer: C
Rationale: Chronic use of high doses of acetaminophen can be hepatotoxic. The other
medications are not associated with hepatotoxicity.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 933
NCLEX: Physiological Integrity
11. To palpate the liver, the nurse
a. presses slowly and firmly over the right costal margin with one hand and
withdraws the fingers quickly after the liver edge is felt.
b. places one hand on top of the other and uses the upper fingers to apply pressure
and the bottom fingers to feel for the liver edge.
c. places one hand under the patient’s lower ribs and presses the left lower rib cage
forward, palpating below the costal margin with the other hand.
d. places one hand on the patient’s back and presses upward and inward with the
other hand below the patient’s right costal margin.
Correct Answer: D
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
39-5
Rationale: The liver is normally not palpable below the costal margin, the nurse needs to push
inward below the right costal margin while lifting the patient’s back slightly with the left hand.
The other methods will not allow palpation of the liver.
Cognitive Level: Application
Text Reference: pp. 937-938
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment
12. When listening to a patient’s abdomen after the patient has eaten, the nurse will be concerned
about
a. high-pitched gurgles.
b. frequent clicking sounds.
c. absent bowel sounds.
d. loud gurgles.
Correct Answer: C
Rationale: Absent bowel sounds may indicate bowel obstruction and require further assessment
by the nurse. The other sounds may normally be heard.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 937, 940
NCLEX: Physiological Integrity
13. When caring for a patient following a needle biopsy of the liver at the bedside, the nurse
should
a. elevate the head of the bed to facilitate breathing.
b. check the patient’s post-biopsy coagulation studies.
c. place the patient on the right side with the bed flat.
d. put pressure on the biopsy site using a sandbag.
Correct Answer: C
Rationale: After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy
site. Coagulation studies are checked prior to the biopsy. A sandbag does not exert adequate
pressure to splint the site.
Cognitive Level: Application
Nursing Process: Implementation
Text Reference: p. 944
NCLEX: Physiological Integrity
14. When documenting the absence of bowel tones in all quadrants of a patient’s abdomen, the
nurse has auscultated the patient’s abdomen for _____ minutes.
a. 8
b. 10
c. 16
d. 20
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
39-6
Correct Answer: D
Rationale: To document absent bowel sounds, the nurse should listen to each quadrant for 5
minutes. The other times are not adequate to ensure that bowel tones are absent.
Cognitive Level: Comprehension
Nursing Process: Assessment
Text Reference: p. 937
NCLEX: Physiological Integrity
15. Which information obtained by the nurse when admitting a patient who is scheduled for an
ultrasound of the gallbladder indicates that the ultrasound may need to be rescheduled?
a. The patient had a high-fat meal the previous evening.
b. The patient took a laxative before bed.
c. The patient has a permanent gastrostomy tube.
d. The patient ate a low-fat bagel an hour previously.
Correct Answer: D
Rationale: Food intake can cause the gallbladder to contract and result in a suboptimal study.
The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous
evening, laxative use, or a gastrostomy tube will not affect the results of the study.
Cognitive Level: Application
Nursing Process: Implementation
Text Reference: p. 941
NCLEX: Physiological Integrity
16. The nurse is obtaining a nursing history from a patient with esophagitis and gastritis. A
question that is appropriate for the nurse to ask during assessment of the patient’s health
perception-health management functional health pattern is,
a. “Do you smoke or use other forms of nicotine?”
b. “Did you have any pain associated with your vomiting?”
c. “What have you eaten in the last 24 hours?”
d. “Have you noticed any changes in your stools?”
Correct Answer: A
Rationale: The health perception-health maintenance pattern includes information about patient
habits that may impact on the GI system, such as smoking. Pain associated with vomiting will be
discussed during assessment of the cognitive-perceptual pattern. A 24-hour dietary recall is
included in the nutritional-metabolic pattern. Changes in stools are assessed in the elimination
pattern.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 934-935
NCLEX: Physiological Integrity
17. When the nurse is assessing an alert and independent older patient in the clinic for
malnutrition risk, the most appropriate initial question is,
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
a.
b.
c.
d.
39-7
“Do you have any difficulty in preparing or eating food?”
“How do you get to the grocery store to buy your food?”
“Are you taking any medications that alter your taste or tolerance of foods?”
“Can you tell me the foods that you have eaten over the past 24 hours?”
Correct Answer: D
Rationale: This question is the most open-ended one and will provide the best overall
information about the patient’s daily intake and risk for poor nutrition. The other questions may
be asked, depending on the patient’s response to the first question.
Cognitive Level: Application
Text Reference: p. 934
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.