Chapter 37: Digestive System Introduction

MULTIPLE CHOICE

1. A nurse is preparing to give a tube feeding using a large syringe. What action should the nurse
implement before starting the infusion?
a. Roll the patient flat.
b. Check for a residual formula and return the residual to his or her stomach.
c. Place the end of the tube in water and check for bubbles.
d. Flush the tube.

ANS: B
Verifying tube placement by pulling up the residual formula is a standard of care for a tube
feeding.

DIF: Cognitive Level: Application REF: p. 708 OBJ: 4

TOP: Tube Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

2. After receiving a tube feeding, a nurse assesses the patient to be sweaty with abdominal
distention and diarrhea. What is the most likely cause of this response?
a. Expected reaction to the tube feeding
b. Dumping syndrome
c. Gastric reflux syndrome
d. Onset of gastroenteritis

ANS: B
Dumping syndrome is caused by infusing a tube feeding too fast or infusing a tube feeding
that is too rich a formula.

DIF: Cognitive Level: Application REF: p. 708 OBJ: 3

TOP: Dumping Syndrome KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A nurse administers promethazine (Phenergan) for nausea. Which extra precautionary action
should the nurse implement because of the common side effect of antiemetic medications?
a. Check vital signs for erratic blood pressure.
b. Add a blanket to prevent chilling.
c. Provide extra water to combat thirst.
d. Put up side rails to prevent falls.

ANS: D
Most antiemetic medications cause drowsiness because of their effects on the central nervous
system, resulting in dizziness and confusion.

DIF: Cognitive Level: Application REF: p. 714 OBJ: 4

TOP: Antiemetic Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. A patient complains about the placement of the total parenteral nutrition (TPN) line and asks
why it cannot be inserted in the arm. What fact regarding the placement of this line should the
nurse base a response on?
a. Arm would limit patient mobility.
b. Subclavian artery allows for ease in dressing the puncture site.
c. Arm prevents the use of large-bore cannulas.
d. Subclavian artery allows for rapid dilution.

ANS: D
The rich TPN solution is rapidly diluted in the larger vessel, preventing phlebitis.

DIF: Cognitive Level: Comprehension REF: p. 709 OBJ: 3

TOP: TPN KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. A patient inquires if this newer type of gastric analysis is going to require passage of a
nasogastric tube. What is the nurse’s most accurate reply?
a. “Yes, but just for the instillation of the dye.”
b. “No. You take a dye orally, which will be excreted in the urine in approximately 2
hours.”
c. “Yes. You will take the dye orally, and then several gastric withdrawals through the
tube will show the dye.”
d. “Yes. Only one withdrawal will be made through the tube, which will be treated
with dye and read in approximately 2 hours.”
ANS: B
Dye is given orally, and if hydrochloric acid is present, the dye will be excreted in the urine in
approximately 2 hours. The older method of taking serial gastric samples every 15 minutes
through a nasogastric tube may still be used.

DIF: Cognitive Level: Application REF: p. 702 OBJ: 1

TOP: Newer Method of Gastric Analysis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. A nurse is caring for a patient receiving total parenteral nutrition (TPN). Which nursing action
is most appropriate to implement?
a. Use a clean technique for site care.
b. Infuse the solution rapidly.
c. Administer medications through the TPN line.
d. Monitor the temperature for elevation.

ANS: D
Temperature should be monitored for signs of potential infection. When caring for a patient
receiving TPN, sterile technique is used for site care. If solution is given too rapidly, the
patient may have circulatory overload. The TPN catheter should never be used for medication
administration.

DIF: Cognitive Level: Application REF: p. 710 OBJ: 4

TOP: TPN KEY: Nursing Process Step: Implementation
 MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. Which patient assessment indicates hyperglycemia with TPN feeding?

a. Increase of urine output
b. Sudden diarrhea
c. Abdominal distention
d. Tachycardia

ANS: A
Increased urine output would indicate a probable increase in blood glucose.

DIF: Cognitive Level: Comprehension REF: p. 710 OBJ: 3

TOP: TPN KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. The TPN feeding is running at 20 mL and is 1 hour behind schedule. What is the most
appropriate initial nursing intervention?
a. Increase the flow rate to 22 mL/hr (10%) and inform the charge nurse.
b. Reposition the patient to the right side and lower the head of the bed.
c. Dilute the thick feeding formula with 10 mL of sterile water and inform the charge
nurse.
d. Document the event and inform the charge nurse.

ANS: D
Increasing the speed of giving TPN feedings is never a consideration because doing so will
cause hyperglycemia. The event should be documented and the charge nurse informed.

DIF: Cognitive Level: Application REF: p. 710 OBJ: 3 | 4

TOP: TPN KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. What is the most current endoscopic procedure for examining the small intestine?
a. Capsule camera
b. Fiberoptic light probe
c. Rigid lighted tubes
d. Flat plate

ANS: A
The capsule camera is swallowed and transmits information about the small bowel to a
receiver on a belt around the patient’s waist.

DIF: Cognitive Level: Knowledge REF: p. 700 OBJ: 1

TOP: Endoscopy KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. A nurse has collected several stool specimens for ova and parasites that are to be sent to the
laboratory. What action is most appropriate for the nurse to implement?
a. Immediately take the specimens to the laboratory to be tested for parasites and ova.
b. Take the specimens to the laboratory to be tested for culture and sensitivity and
leave them for later pickup.
 c. Take the specimens to the refrigerator to be tested later for parasites and ova.
d. Leave the specimens in a warm place until convenient time to deliver to the
laboratory.
ANS: A
Parasite and ova specimens should be immediately taken to the laboratory while the parasites
are still alive. Specimens for evaluating pathogenic organisms should be kept cool.

DIF: Cognitive Level: Application REF: p. 706 OBJ: 1

TOP: Care of Stool Specimens KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

11. Stool softeners are prescribed to promote normal elimination of feces. What is the most
appropriate way to ensure effectiveness of this type of drug?
a. Mouth care
b. Ambulation
c. Adequate fluid intake
d. High-fiber diet

ANS: C
Adequate fluids must be maintained to ensure the liquid is available; otherwise, the fecal mass
will remain hard.

DIF: Cognitive Level: Comprehension REF: p. 713 OBJ: 3

TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

12. Which set of findings best indicates that a patient with intestinal obstruction has achieved
normal hydration?
a. Pulse and blood pressure are within the patient’s norms, mucous membranes are
moist, and fluid intake and output are equal.
b. Pulse rate is strong (at least 60 beats/min), bowel sounds are normal, and a
respiratory rate of 22 breaths/min is recorded.
c. Blood pressure is within the patient’s norm, the temperature is below normal, and
adequate tissue turgor is observed.
d. Mucous membranes are moist, the 24-hour fluid intake is higher than the 24-hour
output, and the pulse rate is elevated.
ANS: A
Vital sign within normal limits, moist mucous membranes, and equal fluid intake and output
are indicative of normal hydration.

DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 4

TOP: Hydration KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. After abdominal surgery, a patient must cough and take deep breaths. How can the nurse best
achieve this with this patient?
a. Withhold analgesics until the patient performs this task.
 b. Help the patient splint the incision with a pillow.
c. Explain that pneumonia occurs if deep breathing is not carried out every 4 hours.
d. Ambulate the patient 40 feet to increase his need for oxygen.

ANS: B
Splinting decreases pain by supporting the muscles, thereby allowing for better lung
expansion.

DIF: Cognitive Level: Application REF: p. 701 OBJ: 3 | 4

TOP: Abdominal Surgery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. A patient is being seen for the first time at a physician’s office. When assisting with the
assessment, a nurse notices abdominal striae. What alternative term should the nurse use when
the patient asks what it is all over her abdomen?
a. Scarring
b. Lesions
c. Rashes
d. Stretch marks

ANS: D
Striae is the medical term for stretch marks.

DIF: Cognitive Level: Knowledge REF: p. 698 OBJ: 3

TOP: Inspection KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

1. What information about when and where specific digestion of food takes place should be
included in a patient teaching plan? (Select all that apply.)
a. Renin breaks down milk protein in the stomach.
b. Lipase breaks down fats in the stomach.
c. Pepsin begins to break down proteins in the stomach.
d. Liver and pancreatic secretions break down fats in the small bowel.
e. Ptyalin (amylase) breaks down carbohydrates in the colon.

ANS: A, B, C, D
Ptyalin (amylase) breaks down carbohydrates in the mouth.

DIF: Cognitive Level: Knowledge REF: p. 692 OBJ: 4

TOP: Digestive Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation