GI Assessment
During a typical head-to-toe assessment, how should the primary RN assess the GI system? (In what order?)
Inspect, auscultation, palpation.
*Percussion is typically only utilized by advanced practice nurses/providers to check for tenderness/inflammation r/t the kidneys.
What disorder involves inflammation of the appendix and commonly presents with RLQ abdominal pain?
Appendicitis
What is a commonly used minimum urine output goal for an adult patient?
Approximately 30 mL/hr, or about 0.5 mL/kg/hr.
Urine output should always be interpreted in context, including fluid status, renal function, medications, and clinical condition.
What is a common symptom of a lower urinary tract infection?
Dysuria — painful or burning urination.
Other findings may include urinary frequency, urgency, and suprapubic discomfort.
A patient with suspected GI bleeding is pale and tachycardic.
What is the priority assessment?
Assess hemodynamic stability and signs of shock.
A patient reports abdominal pain that began around the umbilicus and has now moved to the right lower quadrant.
Which condition should the nurse suspect?
Appendicitis
A patient with cirrhosis is at increased risk for which serious complication involving the esophagus?
Esophageal varices and potentially life-threatening GI hemorrhage.
Which laboratory value is especially useful when evaluating renal function?
A. Hemoglobin
B. Serum creatinine
C. Platelet count
D. Bilirubin
B. Serum creatinine
The nurse is providing discharge teaching to a cisgender female patient on how to prevent urinary tract infections. Which statement is incorrect?
A. "Void immediately after sexual intercourse"
B. "Avoid wearing tight-fitting underwear"
C. "Try to void every 2-3 hours"
D. "Use scented sanitary napkins or tampons during menstruation"
D. "Use scented sanitary napkins or tampons during menstruation"
*chemicals or dye can disrupt pH
A patient has had several days of vomiting and diarrhea and is hypotensive.
What is the priority intervention?
A. Restrict fluids
B. Encourage ambulation
C. Restore circulating volume with prescribed IV fluids
D. Administer a laxative
C. Restore circulating volume with prescribed IV fluids.
The nurse assesses a patient with RUQ abdominal pain.
During palpation, the patient has pain and suddenly stops taking a deep breath.
What does this finding suggest?
A positive Murphy's sign, suggesting acute cholecystitis.
A patient is admitted with acute pancreatitis.
Which dietary modification is commonly anticipated when oral intake resumes?
A. High-fat diet
B. Low-fat diet
C. High-sodium diet
D. High-fiber diet
B. Low-fat diet
Fat stimulates pancreatic secretion. Dietary advancement depends on the patient's condition and provider orders.
A patient with kidney failure develops muscle weakness and ECG changes.
Which electrolyte abnormality should the nurse suspect?
Hyperkalemia
The kidneys play a major role in potassium excretion. Severe hyperkalemia can cause life-threatening dysrhythmias.
A patient with BPH reports increasing difficulty starting urination and a weak urinary stream.
What complication should the nurse monitor for?
Urinary retention
A patient has abdominal distention, vomiting, and suspected bowel obstruction.
Which intervention should the nurse anticipate?
NPO status, IV fluid therapy, and possible NG tube placement for gastric decompression.
A patient reports passing black, sticky, foul-smelling stools.
What is the nurse's primary concern?
Melena associated with an upper GI bleed.
A patient with severe ulcerative colitis develops increasing abdominal distention, severe abdominal pain, fever, and systemic toxicity.
Which complication should the nurse suspect?
Toxic megacolon
This is a potentially life-threatening complication requiring urgent recognition and intervention.
***DAILY DOUBLE***
At around 0200, your 70-year-old female patient, admitted for UTI, calls stating that they can't stop shivering, has chills, and flank pain.
What should you do next? Why??
Take a set of vital signs!
Suspicion of SEPSIS & UTIs are 1 of the most common types of infection linked with sepsis.
Reassess SIRS criteria, and can then activate the nurse-driven Sepsis Protocol if appropriate!
A patient with a kidney stone reports severe colicky flank pain radiating toward the groin.
Which nursing intervention is appropriate?
Provide prescribed analgesia, monitor urine output, strain urine if ordered, encourage appropriate hydration if not contraindicated, and monitor for obstruction/infection.
Which patient should the nurse assess FIRST?
A. Patient with chronic constipation
B. Patient reporting dysuria for 1 day
C. Patient with black, tarry stools and dizziness
D. Patient with chronic nausea
C. Patient with black, tarry stools and dizziness
The combination suggests GI bleeding with possible hemodynamic compromise.
A patient with sudden, severe abdominal pain is assessed, and the nurse now finds a rigid abdomen and worsening vital signs.
Why is this concerning?
Possible perforation with peritonitis.
A patient with cirrhosis develops confusion, personality changes, and asterixis.
What complication is suspected, and what substance is associated with its development?
Hepatic encephalopathy; ammonia accumulation is strongly associated with the condition.
The impaired liver cannot adequately metabolize substances such as ammonia. Treatment may include lactulose as prescribed.
A patient who is having spasms while urinating due to a UTI is prescribed Pyridum (phenazopyridine). Which option below is a normal side effect of the drug?
A. hematuria
B. crystalluria
C. urethra mucous
D. orange-colored urine
D. orange-colored urine
A patient with BPH has not urinated for several hours and reports severe suprapubic discomfort.
What is the priority concern?
Acute urinary retention
Instructor note
The bladder may require prompt decompression according to orders/protocol.
***Daily Double***
A patient with renal failure has a potassium level of 6.8 mEq/L and peaked T waves.
What is the priority?
Treat the severe hyperkalemia immediately and continuously monitor the patient's cardiac rhythm.
Instructor note
Hyperkalemia with ECG changes is a medical emergency because of the risk of fatal dysrhythmias.