GI Assessment
The nurse is assessing bowel sounds in an adult patient.
What is generally considered a normal bowel sound pattern?
Bowel sounds are typically present and occur approximately 5–30 times per minute.
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
Which finding is more characteristic of pyelonephritis than uncomplicated cystitis?
A. Urinary frequency
B. Dysuria
C. Flank pain and fever
D. Urinary urgency
C. Flank pain and fever
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.
A patient presents with fever, chills, flank pain, and costovertebral angle tenderness.
Which condition is most likely?
A. Cystitis
B. Pyelonephritis
C. BPH
D. Nephrotic syndrome
B. Pyelonephritis
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 severe abdominal pain suddenly reports that the pain has dramatically decreased.
The nurse now finds a rigid abdomen and worsening vital signs.
Why is this concerning?
Possible perforation with peritonitis.
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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 has had progressively decreasing urine output.
The patient's creatinine is rising and the patient develops peripheral edema.
What does this pattern suggest?
Worsening renal function/acute kidney injury with fluid retention.
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.
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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.