GI Concerns in Critical Care
A patient with a history of peptic ulcer disease presents with coffee-ground emesis and melena. Which complication should the nurse suspect?
A. Lower GI bleed
B. Upper GI bleed
C. Small bowel obstruction
D. Appendicitis
B. Upper GI bleed
Rationale: Coffee-ground emesis and black, tarry stools (melena) indicate digested blood from the upper GI tract, typically due to peptic ulcers, gastritis, or varices. Bright red hematochezia would suggest a lower GI bleed.
The nurse is caring for a postoperative patient with absent bowel sounds and abdominal distention. Which intervention is most appropriate?
A. Encourage oral fluids.
B. Maintain NPO and insert NG tube for decompression.
C. Administer a laxative.
D. Begin a clear liquid diet.
B. Maintain NPO and insert NG tube for decompression.
Rationale: These findings suggest a paralytic ileus. The bowel needs rest (NPO) and decompression to relieve distention and prevent aspiration or perforation.
A critically ill patient with multiple trauma injuries is receiving mechanical ventilation. Which nutritional approach is most appropriate to initiate within 24–48 hours of admission?
A. Begin parenteral nutrition to avoid aspiration.
B. Start enteral nutrition via nasogastric or orogastric tube.
C. Withhold nutrition until bowel sounds return.
D. Provide only IV fluids until extubation.
B. Start enteral nutrition via nasogastric or orogastric tube.
Rationale: Early enteral nutrition (EN) supports gut integrity, immune defense, and wound healing while reducing infection risk compared to TPN. Nutrition should begin within 24–48 hours if the GI tract is functional.
A 10-year-old child with Type 1 diabetes presents with Kussmaul respirations, fruity breath odor, and blood glucose of 520 mg/dL. What is the nurse’s first priority?
A. Administer IV insulin bolus.
B. Start continuous insulin infusion immediately.
C. Begin isotonic fluid resuscitation with 0.9% normal saline.
D. Administer IV sodium bicarbonate.
C. Begin isotonic fluid resuscitation with 0.9% normal saline.
Rationale: The first priority in DKA management is restoration of circulating volume to correct dehydration and improve perfusion. Insulin is started after initial fluids and once potassium is confirmed ≥3.3 mEq/L. Giving insulin too early may worsen circulatory collapse.
A patient in the ICU suddenly becomes diaphoretic, anxious, and tachycardic. The blood glucose reads 48 mg/dL. What is the nurse’s first action?
A. Administer 1 mg IM glucagon.
B. Give 15–20 g of fast-acting carbohydrates.
C. Notify the provider of the glucose result.
D. Start an IV of 0.9% normal saline.
B. Give 15–20 g of fast-acting carbohydrates.
Rationale: For conscious patients with mild to moderate hypoglycemia, the priority is rapid oral glucose replacement (e.g., juice, glucose tablets). Recheck in 15 minutes. IV dextrose or IM glucagon is reserved for unconscious or NPO patients.
A patient with an acute upper GI bleed has BP 88/60 mmHg and HR 124 bpm. What is the nurse’s priority action?
A. Administer pantoprazole IV.
B. Insert a nasogastric tube for lavage.
C. Establish two large-bore IV lines for fluid resuscitation.
D. Prepare for an emergent endoscopy.
C. Establish two large-bore IV lines for fluid resuscitation.
Rationale: Hypotension and tachycardia indicate hypovolemic shock. The immediate priority is restoring intravascular volume with IV fluids or blood products before diagnostic or pharmacologic interventions.
A patient with severe pancreatitis has a tense, distended abdomen, oliguria, and increasing airway pressures on the ventilator. What complication does the nurse suspect?
A. Peritonitis
B. Abdominal compartment syndrome
C. Gastric perforation
D. Acute cholecystitis
B. Abdominal compartment syndrome
Rationale: Increased intra-abdominal pressure from fluid accumulation compresses organs, leading to decreased urine output, respiratory compromise, and hemodynamic instability. It is a life-threatening emergency requiring decompression.
The nurse is reviewing lab results for a patient receiving total parenteral nutrition (TPN). Which lab finding requires immediate follow-up?
A. Albumin 3.0 g/dL
B. Glucose 278 mg/dL
C. Sodium 136 mEq/L
D. BUN 18 mg/dL
B. Glucose 278 mg/dL
Rationale: Hyperglycemia is a common and serious complication of TPN due to the high glucose concentration. It increases infection risk and osmotic diuresis. The nurse should notify the provider and anticipate insulin therapy or rate adjustment.
A pediatric patient with DKA is started on IV insulin at 0.1 units/kg/hour. One hour later, serum glucose decreases by 120 mg/dL. What should the nurse do next?
A. Increase the insulin rate to improve glucose control.
B. Continue current rate; the drop is appropriate.
C. Decrease the insulin rate to slow the glucose decline.
D. Stop insulin and switch to subcutaneous dosing.
C. Decrease the insulin rate to slow the glucose decline.
Rationale: In children, glucose should decrease no faster than 50–75 mg/dL per hour to avoid rapid osmotic shifts that can cause cerebral edema. The insulin rate should be titrated down to slow the decline.
A nurse is caring for a patient who received insulin but missed breakfast. The patient becomes confused and unresponsive. What treatment should the nurse anticipate?
A. 50 mL of Dextrose 50% IV push
B. 10 units of IV regular insulin
C. 0.9% NS at 500 mL/hr
D. 5 mg IV diazepam
A. 50 mL of Dextrose 50% IV push
Rationale: Severe hypoglycemia with altered LOC requires immediate IV dextrose to restore blood glucose and prevent neurologic injury. If IV access is unavailable, IM glucagon is the next alternative.
The nurse suspects a lower GI bleed in a patient. Which finding best supports this diagnosis?
A. Coffee-ground emesis
B. Melena
C. Hematochezia
D. Occult blood in emesis
C. Hematochezia
Rationale: Hematochezia (bright red blood in stool) is characteristic of a lower GI bleed. Melena and coffee-ground emesis are more consistent with upper GI bleeding.
A patient with BMI 42 undergoes Roux-en-Y gastric bypass. Which postoperative finding requires immediate nursing intervention?
A. Mild nausea after eating
B. Heart rate of 130 bpm and hypotension
C. Early satiety
D. Small serous drainage at incision site
B. Heart rate of 130 bpm and hypotension
Rationale: Tachycardia and hypotension after bariatric surgery may indicate an anastomotic leak, a surgical emergency due to internal bleeding or sepsis risk.
The nurse recognizes that excessive carbohydrate intake in a patient with chronic pulmonary failure may cause which complication?
A. Respiratory alkalosis
B. Increased CO₂ production and respiratory acidosis
C. Hypoglycemia
D. Decreased metabolic demand
B. Increased CO₂ production and respiratory acidosis
Rationale: Metabolism of carbohydrates produces more carbon dioxide than fats or proteins. In patients with pulmonary failure, excess carbs can worsen CO₂ retention and respiratory acidosis.
The nurse is caring for a 12-year-old with DKA whose potassium is 3.1 mEq/L and urine output is adequate. What is the best nursing action?
A. Start insulin infusion immediately.
B. Administer potassium replacement before starting insulin.
C. Delay potassium replacement until after insulin is started.
D. Restrict fluids to prevent further potassium loss.
B. Administer potassium replacement before starting insulin.
Rationale: Even if initial potassium appears normal or elevated, total body potassium is depleted. Insulin drives potassium into cells and can cause life-threatening hypokalemia if levels are not corrected first. Insulin is not initiated until K⁺ ≥3.3 mEq/L.
Which finding best distinguishes diabetic ketoacidosis (DKA) from hyperosmolar hyperglycemic state (HHS)?
A. Serum glucose >600 mg/dL
B. Presence of ketones and metabolic acidosis
C. Severe dehydration
D. Altered mental status
B. Presence of ketones and metabolic acidosis
Rationale: DKA results from absolute insulin deficiency, causing ketone accumulation and metabolic acidosis. HHS has extreme hyperglycemia and hyperosmolarity but minimal or no ketosis. Both can present with dehydration and mental changes.
Which nursing diagnosis is most appropriate for a patient admitted with an acute GI bleed?
A. Impaired gas exchange
B. Risk for deficient fluid volume
C. Chronic low self-esteem
D. Disturbed body image
B. Risk for deficient fluid volume
Rationale: Blood loss leads to hypovolemia, making fluid volume deficit the highest-priority nursing diagnosis. Managing hemodynamic stability is critical to prevent shock.
A patient reports dizziness, palpitations, and diarrhea 20 minutes after eating following gastric bypass surgery. Which intervention is most appropriate?
A. Encourage oral fluids during meals.
B. Offer high-sugar snacks to increase energy.
C. Instruct to eat small, frequent meals and avoid liquids with food.
D. Administer insulin as ordered.
C. Instruct to eat small, frequent meals and avoid liquids with food.
Rationale: These symptoms are consistent with early dumping syndrome due to rapid gastric emptying. Dietary modification is the key management approach to slow gastric transit and reduce symptoms.
A patient with end-stage liver failure is being evaluated for nutrition therapy. Which dietary modification is most appropriate?
A. High-protein, low-carbohydrate diet
B. High-carbohydrate, low-protein diet
C. Low-calorie, low-fat diet
D. High-fiber, high-protein diet
B. High-carbohydrate, low-protein diet
Rationale: The failing liver cannot metabolize ammonia produced from protein breakdown, leading to hepatic encephalopathy. Restricting protein and emphasizing carbohydrates reduces ammonia accumulation and provides needed energy.
A child receiving DKA treatment suddenly complains of severe headache, becomes confused, and has bradycardia with rising blood pressure. What complication should the nurse suspect?
A. Hypoglycemia
B. Cerebral edema
C. Fluid overload
D. Hypokalemia
B. Cerebral edema
Rationale: Cerebral edema is the most serious complication of pediatric DKA, caused by rapid shifts in serum osmolality. Warning signs include headache, altered mental status, bradycardia, and hypertension. The nurse should stop fluids, elevate the head of bed, and prepare to administer mannitol or hypertonic saline.
During treatment of a patient with HHS, which nursing intervention has the highest priority?
A. Administer IV regular insulin bolus.
B. Start IV fluids with 0.9% normal saline.
C. Restrict oral fluids until glucose normalizes.
D. Give sodium bicarbonate to correct alkalosis.
B. Start IV fluids with 0.9% normal saline.
Rationale: Fluid replacement is the cornerstone of HHS therapy to restore intravascular volume and improve perfusion before insulin administration. Insulin is initiated after initial rehydration and electrolyte evaluation.
A patient develops abdominal distention, severe cramping pain, and high-pitched bowel sounds. Which condition should the nurse suspect?
A. Paralytic ileus
B. Peritonitis
C. Mechanical intestinal obstruction
D. Gastric ulcer
C. Mechanical intestinal obstruction
Rationale: High-pitched bowel sounds and cramping pain are hallmark findings of a mechanical obstruction caused by adhesions, hernias, or tumors. Paralytic ileus would present with absent bowel sounds.
A patient recovering from bariatric surgery reports weakness, diaphoresis, and dizziness 2 hours after eating. Which medication might the provider prescribe to help manage this condition?
A. Metoclopramide
B. Octreotide
C. Pantoprazole
D. Ondansetron
B. Octreotide
Rationale: Late dumping syndrome causes postprandial hypoglycemia. Octreotide slows gastric emptying and inhibits insulin release, reducing these symptoms.
A burn patient develops tachycardia, fever, hyperglycemia, and muscle wasting despite adequate fluids. What physiologic process does the nurse recognize?
A. Metabolic acidosis
B. Refeeding syndrome
C. Hypermetabolic stress response
D. Hypovolemic shock
C. Hypermetabolic stress response
Rationale: Severe trauma and burns trigger a stress response with elevated catecholamines and cortisol, causing hypermetabolism, protein catabolism, and increased energy needs. Early, high-protein nutritional support helps minimize lean body mass loss and supports immune recovery.
A nurse caring for a 13-year-old recovering from DKA is preparing to transition from IV to subcutaneous insulin. Which criterion must be met before this transition?
A. Blood glucose <200 mg/dL for 4 hours
B. pH >7.2 but persistent ketones in urine
C. The child is alert, able to eat, and the anion gap is closed
D. Insulin infusion completed with glucose 100 mg/dL
C. The child is alert, able to eat, and the anion gap is closed
Rationale: Transition to subcutaneous insulin occurs once metabolic acidosis has resolved (closed anion gap), the child can tolerate oral intake, and is neurologically stable. IV insulin should overlap with the first SQ dose by 1–2 hours to prevent rebound hyperglycemia.
The nurse caring for a child with DKA closely monitors for which complication during fluid replacement?
A. Pulmonary edema
B. Cerebral edema
C. Hypothermia
D. Hypernatremia
B. Cerebral edema
Rationale: Pediatric patients are especially vulnerable to cerebral edema due to rapid shifts in serum osmolality. Fluids must be replaced slowly over 36–48 hours, and neurologic status must be assessed hourly for headache, altered LOC, bradycardia, or hypertension.