MSN Exam for Gastrointestinal Problems

1. In preparing a client for a colonoscopy procedure, which task is most suitable to delegate to the nursing assistant?

1. Explain the need for clear liquids 1 – 3 days prior to procedure.
2. Reinforce NPO status 8 hours prior to procedure.
3. Administer laxatives 1 – 3 days prior to procedure.
4. Administer an enema the night before the procedure.

2. You would be most concerned about which client having an order for TPN (total parental nutrition) fat emulsion?

1. A client with gastrointestinal obstruction
2. A client with severe anorexia nervosa
3. A client with chronic diarrhea and vomiting
4. A client with a fractured femur

3. You are preparing to administer TPN through a central line. Place the steps for administration in the correct order.

1. Use aseptic technique when handling the injection cap.
2. Thread the IN tubing through an infusion pump.
3. Check the solution for cloudiness or turbidity.
4. Connect the tubing to the central line.
5. Select the correct tubing and filter.
6. Set infusion pump at prescribed rate.
   _____, _____, _____, _____, _____, _____

4. You are caring for a client with peptic ulcer disease. Which assessment finding is the most serious?

1. Projectile vomiting
2. Burning sensation 2 hours after eating
3. Coffee-grounded emesis
4. Board-like abdomen with shoulder pain

5. You are taking an initial history for a client seeking surgical treatment for obesity. Which of the following should be called to the attention of the surgeon before proceeding with additional history or physical assessment?

1. Obesity for approximately 5 years
2. History of counseling for body dysmorphic disorder
3. Failure to reduce weight with other forms of therapy
4. Body weight 100% above the ideal for age, gender and height

6. In educating a client with gastroesophageal reflux disease (GERD), you will teach the client that the drug therapy is a “step-up” approach that depends on the response to the medication. For the drugs listed, what is the anticipated order that the physician will try in the treatment plan?

1. Magnesium trisilicate (Gaviscon) and Famotidine (Pepci AC)
2. Ranitidine (Zantac) 150 mg
3. Pantoprazole (Protonix)
   _____, _____, _____

7. In caring for a client with GERD, which task would be appropriate to assign to the nursing assistant?

1. Share successful strategies for weight reduction.
2. Encourage the client to express concerns about lifestyle modification.
3. Remind the client not to lie down for 2 – 3 hours after eating.
4. Explain the rationale for small frequent meals.

8. You are preparing to give an enteral feeding through a nasogastric tube. Place the steps in the correct order.

1. Assess for bowel sounds.
2. Auscultate tube placement and check pH.
3. Flush the tube with water.
4. Reflush the tube with water.
5. Administer the feeding.
6. Check for residual volume.
   _____, _____, _____, _____, _____, _____

9. Care of which of these clients is most appropriate to assign to the LPN/LVN, under the supervision of an RN?

1. A client with oral cancer who is scheduled in the morning for glossectomy
2. An obese client returned from surgery following a vertical banded gastroplasty
3. A client with anorexia nervosa with muscle weakness and decreased urine output
4. A client with intractable nausea and vomiting related to chemotherapy

10.In planning the post-operative care for a morbidly obese client, how can the expertise of the LPN/LVN best be applied?

1. Obtain an oversized blood pressure cuff and a large-size bed.
2. Set up a reinforced trapeze bar.
3. Assist in the planning of bathing, turning, and ambulation.
4. Design alternatives for routine tasks such as daily weights.

11.A client with proctitis needs a rectal suppository. A senior nursing student assigned to this client tells you that she is afraid to insert the suppository because she has never done it before. What is the most appropriate action in supervising this student?

1. You give the medication and report the student to the instructor.
2. Ask the student to leave the clinical area for being unprepared.
3. Reassign the client to an LPN/LVN.
4. Show the student how to insert the suppository and talk to the instructor.

12.You are teaching the client and family how to do colostomy irrigation. Place the information in the correct order.

1. Hang the container at about shoulder height.
2. Allow the solution to flow slowly and steadily for 5 – 10 minutes.
3. Put 500 – 100 mL of lukewarm water in the container.
4. Allow 30 – 45 minutes for evacuation.
5. Lubricate the stoma cone and gently insert the tubing tip into the stoma.
6. Clean, rinse, and dry skin, and apply a new drainage pouch.
   _____, _____, _____, _____, _____, _____

13.You are caring for a client with a nasogastric (NG) tube. Which task can be delegated to the experienced nursing assistant?

1. Remove the NG tube per physician order.
2. Secure the tape if the client accidentally dislodges the tube.
3. Disconnect the suction to allow ambulation to the toilet.
4. Reconnect the suction after the client has ambulated.

14.In planning a treatment and prevention program of chronic fecal incontinence for an elderly client, which intervention should you try first?

1. Administer a glycerin suppository 15 minutes before evacuation time.
2. Insert a rectal tube at specified intervals each day.
3. Assist the client to the bedpan or toilet 30 minutes after meals.
4. Use incontinence briefs or adult-sized diapers.

15.A client hospitalized with ulcerative colitis reports 10 – 20 small diarrhea stools per day, with abdominal pain prior to defecation. The client appears depressed and underweight and is uninterested in self-care or suggested therapies. What is the priority nursing diagnosis?

1. Diarrhea related to irritated bowel
2. Imbalanced Nutrition: Less Than Body Requirements related to nutrient loss
3. Acute Pain related to increased GI motility
4. Ineffective Therapeutic Regimen related to treatment plan

16.While transferring a dirty laundry bag, a nursing assistant sustains a puncture would to the finger from a contaminated needle. The unit has several clients with hepatitis and AIDS; the source is unknown. Prioritize the instructions that you, as charge nurse, should give to the assistant.

1. Have blood test (s) drawn protocol.
2. Complete and file an incident report.
3. Perform a thorough aseptic Handwashing.
4. Report to the occupational health nurse.
5. Follow up for results and counseling.
6. Begin prophylactic drug therapy.
   _____, _____, _____, _____, _____, _____

17.You are caring for an obese post-operative client who underwent surgery for bowel resection. As the client is moving in bed, he states, “Something popped open.” Upon examination you note wound evisceration. Place the following steps in order for handling this complication.

1. Cover the intestine with sterile moistened gauze
2. Stay calm and stay with the client.
3. Monitor the vital signs especially BP and pulse.
4. Have a colleague gather supplies and contact the physician.
5. Put the client into semi-Fowler’s with knees slightly flexed.
6. Prepare the client for surgery as ordered.
   _____, _____, _____, _____, _____, _____

18.You are caring for a post-operative cholecystectomy client. What should be reported immediately to the physician?

1. The client cannot void 4 hours post-operatively.
2. The client reports shoulder pain.
3. The client reports severe RUQ tenderness.
4. Output does not equal input for the first few hours.

19.In caring for a client with acute viral hepatitis, which task should be delegated to the nursing assistant?

1. Empty the bedpan while wearing gloves.
2. Suggest diversional activities.
3. Monitor dietary preferences.
4. Reports signs and symptoms of jaundice.

20.A client with cirrhosis is at risk for developing complications. Which condition is the most serious and potentially life-threatening?

1. Esophageal varices
2. Ascites
3. Peripheral edema
4. Asterixis (liver flap)

21.For clients coming to the ambulatory care GI clinic, which task would be most appropriate to assign to the LPN/LVN?

1. Teach a client self-care measures for hemorrhoids.
2. Assist the physician in incision and drainage of a pilonidal cyst.
3. Evaluate a client’s response to sitz baths for an anorectal abscess.
4. Describe the basic pathophysiology of an anal fistula to a client.

22.A client underwent an exploratory laparotomy 2 days ago. The physician should be called immediately for which physical assessment finding?

1. Abdominal distention and rigidity
2. NG tube intentionally displaced by client
3. Absent or hypoactive bowel sounds
4. Nausea and occasional vomiting

23.You must rearrange the room assignment for several clients. Which two clients would best suited to put in the same room?

1. A 35-year-old female with copious, intractable diarrhea and vomiting
2. A 43-year-old female second day post-operative cholecystectomy
3. A 53-year-old female with pain related to alcohol-associated pancreatitis
4. A 62-year-old female with colon cancer receiving chemotherapy and radiation

24.As nurse manager, you must select an employee to participate in a hospital committee that will develop client education brochures about common abdominal surgeries and wound care. Who would be the best employee to send to this committee?

1. Newly graduated medical-surgical RN
2. Experienced medical-surgical RN
3. Experienced surgical intensive care unit RN
4. Experienced medical-surgical LPN/LVN

25.A client is admitted through the emergency department for a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Choose all that apply.)

1. Preparation for surgery
2. Barium enema
3. NG tube insertion
4. Abdominal x-ray
5. IV fluids

26.Place the steps in correct order for performing colostomy care.

1. Fit the pouch snugly around the stoma.
2. Assess the color and appearance of the stoma.
3. Wash the skin with mild soap and rinse with warm water.
4. Apply a skin barrier to protect the peristomal skin.
5. Dry the skin carefully.
6. Don a pair of clean gloves.

Answers and Rationales

1. ANSWER B – The nursing assistant can reinforce dietary and fluid restrictions after the RN has explained the information to the client. It is also possible that the nursing assistant can administer the enema; however, special training is required and policies may vary between institutions. Medication administration should be performed by licensed personnel. Focus: Delegation
2. ANSWER D – A client with fractured femur is at risk for fat embolism, so fat emulsion should be used with caution. Vomiting may be a problem if the emulsion is infused too rapidly. TPN is commonly used for gastrointestinal obstruction, severe anorexia nervosa, and chronic diarrhea or vomiting. Focus: Prioritization
3. ANSWERS C, E, B, A, D & F – The solution should not be cloudy or turbid. Prepare the equipment by priming the tubing and threading the pump. To prevent infection, use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. Set the pump at the prescribed rate. Focus: Prioritization
4. ANSWER D – A board-like abdomen with shoulder pain is a symptom of a perforation, which is most lethal complication of peptic ulcer disease. A burning sensation is a typical complaint, which can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee-ground emesis is typical of slower bleeding and will require diagnostic testing. Focus: Prioritization
5. ANSWER B – Body dysmorphic disorder is a preoccupation with an imagined physical defect. Corrective surgery can exacerbate this disorder when the client continues to feel dissatisfied with the results. The other criteria are indicators of candidacy for this treatment. Focus: Prioritization
6. ANSWERS A, B & C – First, antacids and over-the-counter histamine – 2 blockers are used. In step two, prescription histamine – 2 blockers are prescribed. Finally, proton-pump inhibitors are used. Focus: Prioritization
7. ANSWER C – Reminding the client to follow through on advice given by the nurse is an appropriate task for the nursing assistant. The RN should take responsibility for teaching rationale and discussing strategies for the treatment plan and assessing client concerns. Focus: Delegation
8. ANSWERS A, B, F, C, E & D – Assessment is the first step. Checking for tube placement prevents accidentally instilling feeding/medication into the lungs. The amount of residual volume determines whether the amount of the scheduled feeding is appropriate or whether the physician should be notified. Flushing the tube before and after feeding helps maintain tube patency. Focus: Prioritization
9. ANSWER D – Nausea and vomiting are common after chemotherapy. Administration of antiemetics and fluid monitoring can be done by an LPN/LVN. The RN should do the pre-operative teaching for the glossectomy client. Clients returning from surgery need extensive assessment. The client with anorexia is showing signs of hypokalemia and is at risk for cardiac dysrhythmias. Focus: Assignment
10. ANSWER C – The LPN/LVN can assist in the planning of interventions, but the RN should take ultimate responsibility for planning or designing. Obtaining equipment should be delegated to the nursing assistant. Contact physical therapy to set up specialized equipment. Focus: Delegation
11. ANSWER D – Showing the student how to insert the suppository meets that immediate client need and the student’s learning need. The instructor can address the student’s fears and long-term learning needs once he/she is aware of the incident. It is preferable that students express fears and learning needs. The other options will discourage the student’s future disclosure of  clinical limitations and need for additional training. Focus: Supervision/assignment
12. ANSWERS C, A, G, E, B, D, F – Prepare the warm water (cold water can cause cramping) and hang the container at shoulder height (hanging the container too high or too low will alter the rate of flow). Put on a pair of clean gloves to protect your hands from colostomy secretions. Lubricating the stoma and gently inserting will allow the water t flow into the stoma. A slow and steady flow prevents cramps and spillage. Adequate time allows for complete evacuation.  Careful attention to the skin prevents breakdown. Focus: Prioritization
13. ANSWER C – Disconnecting the tube from suction is an appropriate task to delegate. Suction should be reconnected by the nurse, so that correct pressure is checked. If the nursing assistant is permitted to reconnect the tube, the RN is still responsible for checking that the pressure setting is correct. During removal of the tube, there is a potential for aspiration, so the nurse should perform this task. If the tube is dislodged, the nurse should recheck placement before it is secured. Focus: Delegation
14. ANSWER C – The goal of bowel training is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal. If this is not successful, a suppository can be used to stimulate the urge. Incontinence briefs are embarrassing for the client and must be changed frequently to prevent skin breakdown. Routine use of rectal tubes is not recommended because of damage to the mucosa and sphincter tone. Focus: Prioritization
15. ANSWER A – The immediate problem is controlling the diarrhea. Addressing this problem is a step to correcting the nutritional imbalance and decreasing the diarrheal cramping. Self-care and compliance with the treatment plan are important long-term goals that can be addressed when the client is feeling better physically. Focus: Prioritization
16. ANSWERS C, D, B, A, F & E – Immediate decontamination is appropriate because time can affect viral load. Occupational health will direct the employee in filing the correct forms, getting the appropriate laboratory tests, getting appropriate prophylaxis, and following up on results. Focus: Prioritization
17. ANSWERS B, D, E, A, C & F – Stay calm and stay with the client. If the client does anything to increase intra-abdominal pressure, the evisceration will worsen. Have a colleague gather supplies and notify the physician. Putting the client in a semi-Fowler’s position with knees flexed will decrease the strain on the wound site. Covering the site provides protection of tissue. Monitor vital signs particularly for decrease in blood pressure or increase in pulse. Anticipate and prepare the client for emergency surgery. Focus: Prioritization
18. ANSWER C – RUQ is a sign of hemorrhage or bile leak. Ability to void should return within 6 hours post-operatively. Right shoulder pain is related to unabsorbed CO2 and will resolve by placing the client in the Sims’ position. Output that does not equal input after surgery for the first several hours is expected. Focus: Prioritization
19. ANSWER A – The nursing assistant should use infection control precautions for the protection of self, employees, and other clients. Planning and monitoring are RN responsibilities. While the nursing assistants can report valuable information, they should not be responsible for signs and symptoms that can be subtle or hard to detect, such as skin changes. Focus: Delegation
20. ANSWER A – When a client has esophageal varices, the vessels become very fragile and massive hemorrhage can occur. The mortality rate is 30% – 50% after an episode of bleeding. Ascites and edema occur when liver production of albumin fails. Asterixis is a sign of hepatic encephalopathy. Focus:Prioritization
21. ANSWER B – Assisting with procedures in stable clients with predictable outcomes is within the educational scope of the LPN/LVN. Teaching the client about self-care or pathophysiology and evaluating the outcome of interventions are responsibilities of the RN. Focus: Delegation
22. ANSWER A – Distention and rigidity can signal hemorrhage or peritonitis. Physician may also decide that symptoms require a medication to stimulate peristalsis. Absent bowel sounds are expected within the first 24 – 28 hours. Nausea and vomiting are not uncommon and are usually self-limiting, and a PRN order for an antiemetic is usually part of the routine post-operative orders. Assess the client’s reason for pulling tube, and secure as necessary. Focus: Prioritization
23. ANSWERS B & C – Both clients will need frequent pain assessments and medications. Clients with copious diarrhea or vomiting will frequently need enteric isolation. Cancer clients receiving chemotherapy are at risk for immunosuppression and are likely to need reverse isolation. Focus: Assignment
24. ANSWER B – The experienced medical-surgical nurse will know the types of questions that clients generally ask during the pre-operative or discharge teaching. The new graduate may have enthusiasm and knowledge, but will lack practical application. SICU nurses are less involved in pre-operative or discharge teaching. LPN/LVNs can do teaching, but their educational scope does not provide for development of teaching materials and strategies. Focus: Assignment
25. ANSWERS A, C, D & E – Strangulated intestinal obstruction is a surgical emergency. NG tube is for decompression of the intestine. Abdominal x-ray is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and delivery of medication. Barium enema is not ordered if perforation is suspected. Focus: Prioritization
26. ANSWERS F, B, C, E, D & A – Apply a pair of clean gloves before touching the skin. (Note: Visual assessment can be performed without applying gloves; however, the stoma mat ooze or require gentle palpation.) The stoma should be assessed for a healthy pink color. Washing, rinsing, drying, and application of a skin barrier help to protect the skin. A good fit prevents gastric contents from spilling onto the skin. Focus: Prioritization