PCCN Gastrointestinal — Questions and Answers
Question 1: A patient with liver cirrhosis is at risk for hepatic encephalopathy. Which assessment finding most supports this diagnosis?
- Hypoactive bowel sounds
- Clay-colored stools
- Asterixis (flapping hand tremor) (Correct answer)
- Right upper quadrant pain
Correct answer: Asterixis (flapping hand tremor)
Hepatic encephalopathy is a neurological complication of liver cirrhosis caused by the accumulation of toxins, primarily ammonia, in the bloodstream. Asterixis, often called a 'liver flap,' is a characteristic motor disturbance seen in patients with this condition. It indicates impaired neurological function due to the liver's inability to detoxify harmful substances.
Question 2: Which laboratory result is most indicative of acute pancreatitis?
- Elevated alkaline phosphatase
- Elevated amylase and lipase (Correct answer)
- Low bilirubin
- Decreased ALT and AST
Correct answer: Elevated amylase and lipase
Acute pancreatitis involves inflammation of the pancreas, leading to the release of digestive enzymes into the bloodstream. Amylase and lipase are pancreatic enzymes, and their levels become significantly elevated in acute pancreatitis, often several times the normal range. Lipase is generally considered more specific for pancreatitis than amylase.
Question 3: Which intervention is most appropriate for a patient with upper gastrointestinal bleeding and hematemesis?
- Administering proton pump inhibitor (Correct answer)
- Providing oral fluids
- Encouraging ambulation
- Initiating a high-fiber diet
Correct answer: Administering proton pump inhibitor
Upper gastrointestinal bleeding, especially with hematemesis, often results from conditions like peptic ulcers or erosions where stomach acid plays a significant role. Proton pump inhibitors (PPIs) reduce gastric acid secretion, which helps to stabilize the clot, prevent further bleeding, and promote healing of the gastric mucosa. This is a critical intervention to manage the underlying cause and prevent re-bleeding.
Question 4: A nurse caring for a patient with a nasogastric (NG) tube notes abdominal distention and high residual volumes. What is the priority nursing action?
- Increase the feeding rate
- Flush the NG tube with air
- Hold the feeding and notify the provider (Correct answer)
- Position the patient in supine
Correct answer: Hold the feeding and notify the provider
Abdominal distention and high residual volumes in a patient with an NG tube receiving feedings indicate delayed gastric emptying or intolerance to the feeding. Continuing the feeding could lead to aspiration, nausea, vomiting, or further abdominal discomfort. The priority is to stop the feeding to prevent complications and then notify the provider for further assessment and orders.
Question 5: Which finding would be most concerning in a patient with suspected bowel perforation?
- Nausea
- Abdominal cramping
- Rigid, board-like abdomen (Correct answer)
- Hyperactive bowel sounds
Correct answer: Rigid, board-like abdomen
A rigid, board-like abdomen is a classic sign of peritonitis, which is severe inflammation of the peritoneum, often caused by the leakage of gastrointestinal contents into the abdominal cavity due to bowel perforation. This finding indicates a medical emergency requiring immediate surgical intervention. Other symptoms like nausea and cramping are common but less specific for perforation.
Question 6: Which nursing intervention helps prevent complications of portal hypertension in a patient with cirrhosis?
- Encouraging high-protein intake
- Administering lactulose (Correct answer)
- Limiting fluid intake
- Restricting physical activity
Correct answer: Administering lactulose
Portal hypertension in cirrhosis can lead to hepatic encephalopathy due to the accumulation of ammonia and other toxins. Lactulose works by trapping ammonia in the gut and promoting its excretion through the stool, thereby reducing systemic ammonia levels. This intervention directly addresses a major complication of portal hypertension by preventing or treating hepatic encephalopathy.
Question 7: What is the most serious complication associated with esophageal varices?
- Acid reflux
- Aspiration pneumonia
- Massive upper GI bleeding (Correct answer)
- Strangulated hernia
Correct answer: Massive upper GI bleeding
Esophageal varices are dilated blood vessels in the esophagus that develop due to portal hypertension in liver disease. These vessels are fragile and prone to rupture, leading to life-threatening, massive upper gastrointestinal bleeding. This complication is a medical emergency with a high mortality rate, making it the most serious concern.
Question 8: A patient receiving total parenteral nutrition (TPN) via a central line suddenly becomes febrile and hypotensive. What is the nurse’s priority action?
- Increase the TPN infusion rate
- Send the TPN solution for glucose testing
- Stop the TPN and obtain blood cultures (Correct answer)
- Flush the central line with heparin
Correct answer: Stop the TPN and obtain blood cultures
Fever and hypotension in a patient receiving TPN via a central line are strong indicators of a central line-associated bloodstream infection (CLABSI), a serious complication. The priority is to immediately stop the potential source of infection (TPN) and obtain blood cultures to identify the causative organism. This allows for prompt initiation of appropriate antibiotic therapy and prevents further systemic infection.
Question 9: In assessing a patient with cholecystitis, which clinical sign is most commonly expected?
- Left lower quadrant pain
- Murphy’s sign (pain with inspiration during palpation of RUQ) (Correct answer)
- Hematochezia
- Ascites
Correct answer: Murphy’s sign (pain with inspiration during palpation of RUQ)
Cholecystitis is inflammation of the gallbladder, typically caused by gallstones obstructing the cystic duct. Murphy's sign is a classic clinical finding where a patient experiences sharp pain and inspiratory arrest when the examiner palpates the right upper quadrant (RUQ) beneath the liver edge during inspiration. This maneuver causes the inflamed gallbladder to descend and contact the examiner's hand, eliciting pain.
PCCN Gastrointestinal
A patient with liver cirrhosis is at risk for hepatic encephalopathy.
Which assessment finding most supports this diagnosis?