Gastrointestinal Disorders NCLEX: Nursing Questions and Rationale

1. B. Call the healthcare provider while remaining with the client, flex the knees and cover the wound with sterile gauze soaked in sterile saline.

Rationale: The healthcare provider (HCP) must be notified immediately because if the organs are exposed to the outside air they can be contaminated and dry out. Never leave the client with the organs exposed outside the body. While with the client and after calling the HCP, flex the client’s knees to decrease pressure from the abdominal area and cover the wound with sterile gauze soaked in sterile saline solution to keep the organs moist. Using a bed cover over the wound would contaminate the wound and may cause severe infection. Do not allow anyone to touch the eviscerated organs as it could also cause an infection that may lead to septic shock.

2. C. “The drainage amount will decrease daily until the bile duct heals.”

Rationale: As the bile duct gradually heals, the amount of drainage also decreases. Tube removal can be successful within seven days, provided that there is an absence of inflammation, the cystic and common bile ducts are patent, and there is no intraperitoneal leakage. It is unnecessary to inform the healthcare provider immediately if drainage is noted because this is an expected outcome. The fluid may appear bloody for the first day or two, however, the drainage bag will contain greenish to yellowish fluid, which is the color of bile, eventually. Flushing the drainage tube is performed daily or twice daily, therefore, milking the tube is unnecessary and could lead to the entrance of air and pathogens that will disrupt the gastrointestinal system.

3. D. Gastric pH

Rationale: When the vagus nerve is cut, the gastric phase of the stomach does not occur. The gastric phase is stimulated by amino acids and peptides, leading to G cell activation. It accounts for 605 of total acid production. When there is a decrease in gastric acid, the stomach’s pH increases. Emptying of solid decreases due to the removal of the vagally medial relaxation of the pylorus, which means that peristalsis and gastric motility has also decreased.

4. C. Red

Rationale: For the first 24 hours after a partial gastrectomy, the drainage is bloody-red. Then, while the client is under a nasogastric tube with low continuous suction, the color of the drainage comes out as brow-tined after the next day. The brown-tinged drainage color will turn yellow after a few more days. A light green to clear drainage indicates that gastric functioning has been restored and feeding is now possible.

5. B. Stop the feeding and clamp the NG tube.

Rationale: Gastric residual volume monitoring allows healthcare professionals to identify clients with delayed gastric emptying and implement strategies to minimize adverse events. According to a national survey in the United States, 70% of critical nurses use 200 mL as the threshold level for interrupting enteral nutrition. Merely discarding the amount of increased drainage and continuing the feeding would cause reflux from a full stomach and increases the risk of aspiration pneumonia. Before informing the healthcare provider, the nurse must ensure that a proper nursing intervention has been implemented and that these interventions have not solved the situation. Administering metoclopramide, an anti-emetic, would lead to suppressing the client’s urge to vomit even though the stomach is already full and could cause aspiration.

6. A. Corticosteroids

Rationale: Corticosteroids decrease inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. They are used for induction of remission in moderate-to-severe active ulcerative colitis. However, they have no role in maintaining remission because long-term use can cause adverse effects. Antacids and histamine-2 blockers are not indicated for ulcerative colitis; these are agents used for clients diagnosed with gastroesophageal reflux disease. Antibiotics have been used as an adjunct to steroid therapy but have not altered outcomes.

7. D. Bowel perforation

Rationale: Bowel perforation in ulcerative colitis may occur when chronic inflammation and ulceration weaken the wall to such an extent that a hole develops in the intestinal wall. This perforation is potentially life-threatening. Bowel obstruction, abscesses, and fistulas are complications of Crohn’s disease, which result from swelling and the formation of scar tissue.

8. C. Perform interventions for hypovolemia.

Rationale: The goal of treatment in upper GI bleeding is to correct shock or hypovolemia. In addition to intravenous infusion, the client may need a transfusion of packed RBCs. severe blood loss leads to hypovolemia and hemorrhagic shock, not hypervolemia. Before the source of bleeding can be identified and a diagnosis can be made, it is imperative to resuscitate the hemodynamically unstable client to stabilize them enough so that further tests can be performed.

9. A. Crohn disease

Rationale:  A cobblestone appearance can occur in a number of hollow organs with mucosa, most commonly in the bowel, in the setting of Crohn disease. Longitudinal and circumferential fissures and ulcers separate islands of the mucosa, giving it an appearance reminiscent of cobblestones. Endoscopic findings of ulcerative colitis include loss of vascular pattern, granular and fragile mucosa, and ulcerations. The endoscopic findings in chronic gastritis caused by H. pylori may include areas of intestinal metaplasia. At endoscopy, gastric ulcers appear as discrete mucosal lesions with punched-out smooth ulcer base, which is often filled with whitish fibrinoid exudates.

10. B. Ammonia

Rationale: An elevated blood ammonia level is the classic laboratory abnormality reported in clients diagnosed with hepatic encephalopathy. It is theorized that neurotoxic substances, including ammonia and manganese, may gain entry into the brain in the setting of liver failure. Amylase, calcium, and potassium levels are indirectly affected in hepatic encephalopathy. Hypokalemia may be caused by an increase in ammonia levels, as potassium deficiency decreases gene expression, protein synthesis, and growth. Hypocalcemia occurs in these clients because of vitamin D-dependent metabolism. Increased amylase levels can be found in clients diagnosed with cholecystitis, pancreatitis, or peptic ulcer disease.

11. B. Monitoring for serum glucose

Rationale: Pancreatic cancer cells depend heavily on glucose for growth. To compensate for the inefficient energy production and meet the growing need for energy and biosynthesis, pancreatic cancer cells have a high requirement for glucose and exhibit increased glucose uptake. Therefore hyperglycemia might increase the risk of tumor growth by providing more glucose to fuel tumor growth. Creatinine phosphokinase (CPK) is an enzyme important for muscle function. These enzymes can be found in the brain, lungs, heart, and skeletal muscles. The pancreas is not a muscle, therefore, CPK is not released into the bloodstream when there is damage to the pancreas. Carcinoembryonic antigen (CEA) is not a sensitive or specific tumor marker for pancreatic cancer because benign and malignant conditions other than pancreatic cancer can lead to elevated CEA levels. A radioimmunoassay (RIA) can be used for the detection of the disease’s development after the diagnosis of pancreatic cancer.

12. D. Administer NSAIDs as prescribed.

Rationale: With the potential for hemorrhage, nonsteroidal anti-inflammatory agents (NSAIDs) should be avoided. Pain medications can mask or delay symptoms associated with liver injury, therefore, the administration of analgesics must be minimized for clients under observation. PT or aPTT should be measured in clients who have a history of blood dyscrasias, who have synthetic problems, or who take anticoagulant medications. Initial volume resuscitation with a crystalloid solution is imperative; a fluid bolus of lactated Ringer or normal saline should be given to clients with evidence of shock. The client may be in respiratory distress if the trauma is severe; endotracheal intubation may be performed to secure the airway of any client who is unable to maintain the airway or who has potential airway threats.

13. C. “I might be getting sick again when I start vomiting and easily tires.”

Rationale: Some clients clear hepatitis B virus (HBV) and develop anti-HBs; however, as long as the individual has antibodies to hepatitis B core antigen, he or she is at risk for reactivation because HBV is an incurable disease. HBV is a blood-borne disease that can be transmitted through receiving a transfusion of HBV-infected blood, therefore, blood donation is prohibited in these clients. Since HBV does not have a cure, alcohol consumption is not indicated for these clients because alcohol use increases the risk of progression of chronic HBV. HBV persists in the blood for decades after clinical recovery from acute hepatitis despite the presence of serum antibodies. There is no immunity from HBV.

14. D. Administer IV diazepam to the IV port proximal to the vein.

Rationale: IV diazepam is highly absorbed in plastic materials of administration sets for intravenous infusions. This can be detrimental as it should be delivered to the client at the administered amount for efficacy and safety. Therefore, administering the drug to the IV port closest to the vein limits the amount absorbed by the plastic tubing. Sedative agents such as diazepam are given to clients before an endoscopic procedure to ensure that they are comfortable and relaxed during the procedure and to decrease the pain. However, the use of diazepam as a sedative is used in a limited manner because it can cause severe side effects such as respiratory depression, profound sedation, and coma. Diazepam is a Schedule IV controlled substance with the potential for abuse. Infusing diazepam rapidly increases the risk of respiratory depression symptoms and possible diazepam overdose. Diazepam is not diluted in dextrose with glucose because it can alter its therapeutic effects.

15. A. Sterile saline solution and sterile gauze

Rationale: Normal sterile saline solution is regarded as the most appropriate and preferred cleansing solution because it is a non-toxic, isotonic solution that does not damage healing tissues and organs. A suture kit will be needed later to close up the eviscerated wound; but initially, to cover the wound and exposed organs, a sterile gauze soaked in sterile saline is needed. Using sterile water may be non-toxic to tissues but it is hypotonic and may cause cell lysis.

16. B. Administration of blood and fluids.

Rationale: The goal of therapy in upper GI bleeding (UGIB) is to correct shock and coagulation abnormalities and to stabilize the client so that further evaluation and treatment can proceed. In addition to IV fluids, the client may need a transfusion of packed RBCs. Monitoring of the blood pressure than central venous pressure is already sufficient, as systolic blood pressure is a sensitive clinical marker for helping to predict mortality in UGIB. Promoting increased oral intake is appropriate, but it is not adequate enough to stabilize the client who might be going into shock, and not possible for a client who is not capable of oral intake. Monitoring laboratory test results is a correct intervention but would not help much in stabilizing the client.

17. B. Provide frequent mouth care.

Rationale: Clients who are on nothing per orem (NPO) typically suffer from a dry mouth and frequent thirst. To increase comfort and relieve dry mouth, it is important to perform oral care for these clients. Relief from dry mouth may also lessen the discomfort of being thirsty frequently. Limit the client’s intake of ice chips because ice chips stimulate gastric functioning and may cause vomiting. Increasing the IV rate will not relieve the client’s thirst, and is not a nursing responsibility. Diversional activities are appropriate for pain and will not aid in relieving the client’s thirst.

18. D. Malodorous, yellowish or brownish liquid output

Rationale: The consistency of an ileostomy output may be very loose after bowel surgery, but over time, the small bowel gradually adapts and absorbs more water so the stoma output should thicken up to a porridge-like consistency. It can be yellowish, greenish, or brownish, depending on the client’s diet and medications. The output from tan ascending colon colostomy is often liquid to semiliquid and is located in the low to the middle right side of the abdomen. A pasty-to-formed consistency is a characteristic of an output from the descending colostomy. A liquid-to-pasty consistency is common in the output of a transverse colostomy.

19. B. An older adult male with a low-fat, high-fiber diet

Rationale: Epidemiological studies have linked an increased risk of colorectal cancer with a diet high in red meat and animal fat, low-fiber diets, and a low overall intake of fruits and vegetables. A study found that a high intake of fiber was associated with a reduced risk of colorectal cancer. Clients younger than 50 years (an age group that is experiencing rising rates of colorectal cancer) were shown to have abdominal pain as the most common symptom of colorectal cancer, which makes them more likely to present to a healthcare provider in the year before diagnosis.

20. B. misoprostol

Rationale: Misoprostol is currently approved only for the prevention and treatment of NSAID-induced gastric ulcers in clients taking NSAIDs and at high risk for ulceration. Famotidine decreases the production of stomach acid and is FDA-approved for the treatment of duodenal ulcers, gastric ulcers, and GERD. Sucralfate is a medication used to treat duodenal ulcers, epithelial wounds, chemotherapy-induced mucositis, radiation proctitis, ulcers in Behcet disease, and burn wounds. Calcium carbonate is an inorganic salt primarily used in the management and treatment of low calcium conditions, GERD, CKD, and various other indicated conditions. It is classified as a calcium supplement, antacid, and phosphate binder.

21. D. The client’s bleeding occurred two hours earlier.

Rationale: Coffee-ground emesis is an indication of upper GI bleeding. However, the blood is not fresh or bright red. By the time the vomiting reflex was triggered, the blood had been in the GI tract long enough to begin to dry, congeal, and turn a darker color. Before a blood transfusion can be done, the client needs to undergo laboratory tests and diagnostic imaging to identify the source of bleeding and choose the appropriate intervention. Coffee-ground emesis does not indicate active bleeding because the blood already had time to coagulate and turn coffee brown or black. Gavage will be needed prior to the endoscopy to clear the stomach of the debris and clots. It is not intended to be an intervention for UGIB.

22. A. “I’ll exclude red meat and beans from my diet.”

Rationale: Red meat is not indicated for clients diagnosed with acute liver failure, as well as any processed meat. Protein cannot be adequately processed in clients with liver failure. Waste products may build up and affect the brain if a high-protein diet is utilized. The client’s diet must be low in fat, sugar, and sodium. The body has difficulty processing these foods which may exacerbate liver failure.

23. C. Assess the client’s knowledge about the procedure.

Rationale: Assessment is always the first step in managing any client. The nurse needs to determine the amount of knowledge that the client has about the procedure so that misconceptions can be corrected and additional information can be provided. Providing photos of a successful colostomy may be appropriate once the client has a better understanding of the procedure. Allowing another client with a colostomy to visit may occur after the procedure so that both can share insights about their common experience. Providing written materials about colostomy care is most appropriate during discharge teaching to aid in the retention and recall of the instructions.

24. D. Upper GI tract

Rationale: The anatomic landmark that separates upper and lower bleeds is the ligament of Treitz. Bleeding that originates above the ligament of Treitz usually presents as melena, whereas bleeding that originates below most commonly presents as hematochezia. Melena is dark, black, and tarry feces that typically has a strong characteristic odor caused by the digestive enzyme activity and intestinal bacteria on hemoglobin. Hematochezia is the passing of bright red blood via the rectum.

25. B. “Abdominal pain is usually a late symptom of the disease.”

Rationale: In stomach cancer, all physical signs are late events. By the time these symptoms develop, the disease is almost invariably too far advanced for the curative process. Unfortunately, only a minority of clients with stomach cancer who undergo surgical resection will be cured of the disease. Most clients have a recurrence. Neoadjuvant chemotherapy does not influence morbidity and perioperative mortality rates in gastric cancer. Adjuvant radiotherapy is associated with improvements in both overall and relapse-free survival and reductions in locoregional failure, but it does not guarantee a successful treatment. Total parenteral nutrition may enhance tumor growth.

26. C. Irrigate continuously until the solution is clear.

Rationale: Once the wound has been sufficiently irrigated, no foreign material remains, and the solution is clear, a wound dressing or primary repair of the wound can be performed. The upper limit of pressure where injury to tissues may occur is 70 PSI. Rapid irrigation may exceed this pressure and damage the tissues. Wound dressing is dependent upon the kind of wound. After irrigation, a wet-to-dry dressing may be used to avoid the dressings adhering to the wound. However, the dressing must be monitored strictly because moist surroundings are a common breeding grounds for infection.

27. D. “The stoma may bleed at first when slightly touched.”

Rationale: Stomas are very vascular because it has a lot of blood vessels near the surface, which means they can bleed easily due to a sufficient blood supply, at least for the first few days after surgery. A stoma typically protrudes above the skin, is pink to red in color, moist, round, and with no nerve sensations. The swelling of the stoma must subside after a few days. A burning sensation under the stoma plate may suggest that it is ill-fitted and may have caused injury to the skin below it. A dark or bluish stoma indicates a lack of oxygen and should be reported to the healthcare provider.

28. A. “Don’t worry about the future; just focus on your recovery now.”

Rationale: Sometimes, when the client is seriously ill or distressed, the nurse may be tempted to offer hope. False assurance may tend to discourage the client from further expressing their feelings. Providing the client with sources they can ask for support from may lighten their burden slightly more than being expected to hold themselves up without any support. When nurses are present with their clients, it shows clients that they are valued and worth their time and attention. Confrontation, such as talking about the future implications of the disease, can help the client break destructive routines or understand the state of their current situation.

29. D. “I will be assisting you in turning from side to side every two hours.”

Rationale: Turning the postoperative client from side to side will help prevent venous stasis and improve muscle tone. Due to the client;’s position during surgery, the reverse Trendelenburg, the client has decreased venous return. To recover from it, the nurse may assist the client in turning every two hours as appropriate. Early ambulation is also recommended for postoperative clients as soon as possible.

30. B. Promote rest after small, frequent meals.

Rationale: The client may experience anorexia during the acute phase of hepatitis B, therefore rest periods and sleep patterns must be excellent to avoid expending too much energy. Small, frequent meals allow the client to eat without feeling too full and uncomfortable after. A normal or decreased protein intake will help liver regeneration. The liver cannot process protein anymore, therefore if more protein is taken in, wastes may accumulate in the body and brain, which may lead to hepatic encephalopathy. The client may need to rest more often so that they can relax and use their remaining energy for healing.

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