Answers and Rationale1. Answer: 4. A hiatal hernia is caused by weakness of the diaphragmic muscle and

increased intra-abdominal—not intrathoracic—pressure. This weakness allows the stomach

to slide into the esophagus. The esophageal supports weaken, but esophageal muscle

weakness or increased esophageal muscle pressure isn’t a factor in hiatal hernia.

2. Answer: 1. Obesity may cause increased abdominal pressure that pushes the lower

portion of the stomach into the thorax.

3. Answer: 3. Esophageal reflux is a common symptom of hiatal hernia. This seems to be

associated with chronic exposure of the lower esophageal sphincter to the lower pressure of

the thorax, making it less effective.

4. Answer: 3. A barium swallow with fluoroscopy shows the position of the stomach in

relation to the diaphragm. A colonoscopy and a lower GI series show disorders of the

intestine.

5. Answer: 1. Recognizing the rupture of esophageal varices, or hemorrhage, is the focus of

nursing care because the client could succumb to this quickly. Controlling blood pressure is

also important because it helps reduce the risk of variceal rupture. It is also important to

teach the client what varices are and what foods he should avoid such as spicy foods.

6. Answer: 4. The EGD can visualize the entire upper GI tract as well as allow for tissue

specimens and electrocautery if needed. The barium swallow could locate a gastric ulcer. A

CT scan and an abdominal x-ray aren’t useful in the diagnosis of an ulcer.

7. Answer: 2. Ranitidine is a histamine-2 receptor antagonist that reduces acid secretion by

inhibiting gastrin secretion.

8. Answer: 3. The discomfort of reflux is aggravated by positions that compress the

abdomen and the stomach. These include lying flat on the back or on the stomach after a

meal of lying on the right side. The left side-lying position with the head of the bed elevated

is most likely to give relief to the client.

9. Answer: 1. In a Billroth II procedure the proximal remnant of the stomach is anastomased

to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of

gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric

surgery, unless specifically ordered by the physician. In this situation, the nurse would

clarify the order.

10. Answer: 2. The nurse should instruct the client to decrease the amount of fluid taken at

meals and to avoid high carbohydrate foods including fluids such as fruit nectars; to assume

a low-Fowler’s position during meals; to lie down for 30 minutes after eating to delay gastric

emptying; and to take antispasmidocs as prescribed.

11. Answer: 2. A soft toothbrush should be used to brush the client’s teeth after each meal

and more often as needed. Mechanical cleaning is necessary to maintain oral health,

simulate gingiva, and remove plaque. Assessing the oral cavity and recording observations

is the responsibility of the nurse, not the nursing assistant. Swabbing with a safe foam

applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying

irritant and is not recommended for frequent use.

12. Answer: 3. The most likely complication of an endoscopic procedure is perforation. A

sudden temperature spike with 1 to 2 hours after the procedure is indicative of a perforation

and should be reported immediately to the physician. A sore throat is to be anticipated after

an endoscopy. Clients are given sedatives during the procedure, so it is expected that they

will display signs of sedation after the procedure is completed. A lack of appetite could be

the result of many factors, including the disease process.

13. Answer: 2. A Billroth II procedure bypasses the duodenum and connects the gastric

stump directly to the jejunum. The pyloric sphincter is removed, along with some of the

stomach fundus.

14. Answer: 1. About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is

normally brown, which indicates digested blood. Bile green or cloudy white drainage is not

expected during the first 12 to 24 hours after a subtotal gastrectomy. Drainage during the

first 6 to 12 hours contains some bright red blood, but large amounts of blood or excessively

bloody drainage should be reported to the physician promptly.

15. Answer: 3. Nausea, vomiting, or abdominal distention indicated that gas and secretions

are accumulating within the gastric pouch due to impaired peristalsis or edema at the

operative site and may indicate that the drainage system is not working properly. Saline

solution is used to irrigate nasogastric tubes. Hypotonic solutions such as water increase

electrolyte loss. In addition, a physician’s order is needed to irrigate the NG tube, because

this procedure could disrupt the suture line. After gastric surgery, only the surgeon

repositions the NG tube because of the danger of rupturing or dislodging the suture line.

The amount of suction varies with the type of tube used and is ordered by the physician.

High suction may create too much tension on the gastric suture line.

16. Answer: 4. An appropriate expected outcome is for the client to achieve optimal

nutritional status through the use of oral feedings or total parenteral nutrition (TPN). TPN

may be used to supplement oral intake, or it may be used alone if the client cannot tolerate

oral feedings. The client would not be expected to regain lost weight within 1 month after

surgery or to tolerate a normal dietary intake of three meals per day. Nausea and vomiting

would not be considered an expected outcome of gastric surgery, and regular use of

antiemetics would not be anticipated.

17. Answer: 4. Clients with GERD can develop pulmonary symptoms such as coughing,

wheezing, and dyspnea that are caused by the aspiration of gastric contents. GERD does

not predispose the client to the development of laryngeal cancer. Irritation of the esophagus

and esophageal scar tissue formation can develop as a result of GERD. However, GERD is

more likely to cause painful and difficult swallowing.

18. Answer: 1. Esophageal reflux worsens when the stomach is overdistended with food.

Therefore, an important measure is to eat small, frequent meals. Fluid intake should be

decreased during meals to reduce abdominal distention. Avoiding air swallowing does not

prevent esophageal reflux. Food intake in the evening should be strictly limited to reduce

the incidence of nighttime reflux, so bedtime snacks are not recommended.

19. Answer: 4. The body reacts to perforation of an ulcer by immobilizing the area as much

as possible. This results in boardlike muscle rigidity, usually with extreme pain. Perforation

is a medical emergency requiring immediate surgical intervention because peritonitis

develops quickly after perforation. An intestinal obstruction would not cause midepigastric

pain. Esophageal inflammation or the development of additional ulcers would not cause a

rigid, boardlike abdomen.

20. Answer: 3 and 4. Vomiting and weight loss are common with gastric ulcers. Clients with

a gastric ulcer are most likely to complain of a burning epigastric pain that occurs about one

hour after eating. Eating frequently aggravates the pain. Clients with duodenal ulcers are

more likely to complain about pain that occurs during the night and is frequently relieved by

eating.

21. Answer: 2, 4, and 5. Following a gastroscopy, the nurse should monitor the client for

complications, which include perforation and the potential for aspiration. An elevated

temperature, complaints of epigastric pain, or the vomiting of blood (hematemesis) are all

indications of a possible perforation and should be reported promptly. A sore throat is a

common occurrence following a gastroscopy. Clients are usually sedated to decrease

anxiety and the nurse would anticipate that the client will be drowsy following the procedure.

22. Answer: 2. Black, tarry stools are an important warning sign of bleeding in peptic ulcer

disease. Digested blood in the stomach causes it to be black. The odor of the stool is very

stinky. Clients with peptic ulcer disease should be instructed to report the incidence of black

stools promptly to their physician.

23. Answer: 2. Based on the data provided, the most appropriate nursing diagnosis would

be Disturbed Sleep pattern. A client with a duodenal ulcer commonly awakens at night with

pain. The client’s feelings of anxiety do not necessarily indicate that she is coping

ineffectively.

24. Answer: 2 and 3. The symptoms of nausea and dizziness in a client with peptic ulcer

disease may be indicative of hemorrhage and should not be ignored. The appropriate

nursing actions at this time are for the nurse to monitor the client’s vital signs and notify the

physician of the client’s symptoms. To administer an antacid hourly or to wait one hour to

reassess the client would be inappropriate; prompt intervention is essential in a client who is

potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician

of assessment findings and then initiate oxygen therapy if ordered by the physician.

25. Answer: 3. Ranitidine blocks secretion of hydrochloric acid. Clients who take only one

daily dose of ranitidine are usually advised to take it at bedtime to inhibit nocturnal secretion

of acid. Clients who take the drug twice a day are advised to take it in the morning and at

bedtime.

26. Answer: 3. It is most likely that the client is experiencing a side effect of the antacid.

Antacids with aluminum salt products, such as aluminum hydroxide, form insoluble salts in

the body. These precipitate and accumulate in the intestines, causing constipation.

Increasing dietary fiber intake or daily exercise may be a beneficial lifestyle change for the

client but is not likely to relieve the constipation caused by the aluminum hydroxide.

Constipation, in isolation from other symptoms, is not a sign of bowel obstruction.

27. Answer: 4. Antacids are most effective if taken 1 to 3 hours after meals and at bedtime.

When an antacid is taken on an empty stomach, the duration of the drug’s action is greatly

decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus

increasing the therapeutic action of the drug. Antacids should be administered about 2

hours after other medications to decrease the chance of drug interactions. It is not

necessary to decrease fluid intake when taking antacids.

28. Answer: 2. Chronic gastritis causes deterioration and atrophy of the lining of the

stomach, leading to the loss of the functioning parietal cells. The source of the intrinsic

factor is lost, which results in the inability to absorb vitamin B12. This leads to the

development of pernicious anemia.

29. Answer: 2. Indomethacin (Indocin) is a NSAID and can cause ulceration of the

esophagus, stomach, duodenum, or small intestine. Indomethacin is contraindicated in a

client with GI disorders.

30. Answer: 2. Following cholecystectomy, drainage from the T-tube is initially bloody and

then turns to green-brown. The drainage is measured as output. The amount of expected

drainage will range from 500 to 1000 ml per day. The nurse would document the output.

31. Answer: 1. Cimetidine (Tagamet), a histamine H2 receptor antagonist, will decrease the

secretion of gastric acid. Sucralfate (Carafate) promotes healing by coating the ulcer.

Antacids neutralize acid in the stomach. Omeprazole (Prilosec) inhibits gastric acid

secretion.

32. Answer: 4. Option 4 describes the procedure for a pyloroplasty. A vagotomy involves

cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the

stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the

tissue that produces hydrochloric acid.

33. Answer: 4. A vagotomy, or cutting the vagus nerve, is done to eliminate

parasympathetic stimulation of gastric secretion.

34. Answer: 2. During an acute “gallbladder attack,” the client may complain of severe right

upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the

pattern on dermatomes in the body.

35. Answer: 4. The client should be monitored closely for signs and symptoms of

hemorrhage, such as bright red blood in the nasogastric tube suction, tachycardia, or a drop

in blood pressure. Gastric pH may be monitored to evaluate the need for histamine-2

receptor antagonists. Bowel sounds may not return for up to 72 hours postoperatively.

Nutritional needs should be addressed soon after surgery.

36. Answer: 2. Antacids aren’t helpful in perforation. The client should be treated with

antibiotics as well as fluid, electrolyte, and blood replacement. NG tube suction should also

be performed to prevent further spillage of stomach contents into the peritoneal cavity.

37. Answer: 3. The mucosal barrier fortifiers stimulate mucus production and prevent

hydrogen ion diffusion back into the mucosa, resulting in accelerated ulcer healing. Antacids

neutralize acid production.

38. Answer: 4. Obesity is a known cause of gallstones, and maintaining a recommended

weight will help protect against gallstones. Excessive dietary intake of cholesterol is

associated with the development of gallstones in many people. Dietary protein isn’t

implicated in cholecystitis. Liquid protein and low-calorie diets (with rapid weight loss of

more than 5 lb [2.3kg] per week) are implicated as the cause of some cases of cholecystitis.

Regular exercise (30 minutes/three times a week) may help reduce weight and improve fat

metabolism. Reducing stress may reduce bile production, which may also indirectly

decrease the chances of developing cholecystitis.

39. Answer: 3. Murphy’s sign is elicited when the client reacts to pain and stops breathing.

It’s a common finding in clients with cholecystitis. Periumbilical ecchymosis, Cullen’s sign, is

present in peritonitis. Pain on deep palpation and release is rebound tenderness. Tightening

up abdominal muscles in anticipation of palpation is guarding.

40. Answer: 2. An abdominal ultrasound can show if the gallbladder is enlarged, if

gallstones are present, if the gallbladder wall is thickened, or if distention of the gallbladder

lumen is present. An abdominal CT scan can be used to diagnose cholecystitis, but it

usually isn’t necessary. A barium swallow looks at the stomach and the duodenum.

Endoscopy looks at the esophagus, stomach, and duodenum.

41. Answer: 2. The client with acute cholecystitis should first be monitored for perforation,

fever, abscess, fistula, and sepsis. After assessment, antibiotics will be administered to

reduce the infection. Lithotripsy is used only for a small percentage of clients. Surgery is

usually done after the acute infection has subsided.

42. Answer: 4. Conservative therapy for chronic cholecystitis includes weight reduction by

increasing physical activity, a low-fat diet, antacid use to treat dyspepsia, and

anticholinergic use to relax smooth muscles and reduce ductal tone and spasm, thereby

reducing pain.

43. Answer: 3. The client with a duodenal ulcer may have bleeding at the ulcer site, which

shows up as melena (black tarry poop). The other findings are consistent with a gastric

ulcer.

44. Answer: 4. Pain on empty stomach is relieved by taking foods or antacids. The other

symptoms are those of a gastric ulcer.

45. Answer: 1. NG insertion technique is to have the client first tilt his head back for

insertion into the nostril, then to flex his neck forward and swallow. Extension of the neck (2)

will impede NG tube insertion.

46. Answer: 3. As the liver cells become fatty and degenerate, they are no longer able to

accommodate the large amount of blood necessary for homeostasis. The pressure in the

liver increases and causes increased pressure in the venous system. As the portal pressure

increases, fluid exudes into the abdominal cavity. This is called ascites.

47. Answer: 3. The respiratory system can become occluded if the balloon slips and moves

up the esophagus, putting pressure on the trachea. This would result in respiratory distress

and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if

distress occurs. This is a safety intervention.

48. Answer: 2. Peptic ulcer disease is characteristically gnawing epigastric pain that may

radiate to the back. Vomiting usually reflects pyloric spasm from muscular spasm or

obstruction. Cancer (1) would not evidence pain or vomiting unless the pylorus was

obstructed.

49. Answer: 3. An NG tube insertion is the most appropriate intervention because it will

determine the presence of active GI bleeding. A Miller-Abbott tube (1) is a weighted,

mercury-filled ballooned tube used to resolve bowel obstructions. There is no evidence of

shock or fluid overload in the client; therefore, an arterial line (2) is not appropriate at this

time and an IV (4) is optional.

50. Answer: 1. These drugs inhibit action of histamine on the H2 receptors of parietal cells, thus reducing gastric acid output.