GI PCCN Exam 52 Questions with Verified Answers,100% CORRECT

GI PCCN Exam 52 Questions with Verified Answers The most common causative organism of antibiotic-associated colitis is A. Clostridium difficile. B. Staphylococcus aureus. C. Salmonella. D. Escherichia coli. - CORRECT ANSWER A. Clostridium difficile is an anaerobic gram-positive, spore-forming, toxin-producing bacillus that causes antibiotic-associated colitis. It colonizes the human intestinal tract after the normal gut flora have been altered by antibiotic therapy. It produces exotoxins that lead to inflammation and diarrhea. Antibiotic use is the most common risk factor for C. difficile-associated diarrhea (CDAD). Other risk factors include advanced age, hospitalization, and severe illness. The antibiotics most frequently implicated in CDAD include fluoroquinolones (e.g., ciprofloxacin), clindamycin, broad-spectrum penicillins, and cephalosporins. Symptoms of CDAD include watery diarrhea (up to 10 or 15 times daily), lower abdominal pain and cramping, low grade fever, and leukocytosis. C difficile is highly transmissible and can be cultured from nearly any surface, including items in patient rooms as well as the hands, clothing, and stethoscopes of health care workers. Infection is easily transmitted between patients and between healthcare workers and patients. Treatment includes stopping the causative antibiotic; infection control practices, including contact precautions and hand washing with soap and water (not alcohol based hand cleaners); and administration of metronidazole or vancomycin. Staphylococcus aureus is a leading cause of both community-acquired and healthcare-acquired bacteremia. A methicillin resistant form (MRSA) commonly manifests as skin and soft tissue infections (including wound infections), bacteremia, or pneumonia. Risk factors for MRSA include hospitalization or residence in a long term care facility, recent antibiotic therapy, HIV infection, injection drug use, hemodialysis, sharing of needles, and sharing of sports equipment. Treatment includes antibiotics: clindamycin, trimethoprim-sulfamethoxazole (Bactrim, Esophageal varices are caused by: A. Portal vein atrophy from diminished blood flow. B. Congenital esophageal aneurysms. C. A high level of alcohol content in the esophagus. D. Obstruction of and hypertension within the portal vein with resultant shunting of blood to the esophageal veins. - CORRECT ANSWER D. Although esophageal varices can be seen as a complication of alcoholism, they are not related to any alcohol in the esophagus. Esophageal varices are caused by liver disease (often the result of chronic alcoholism). Liver disease increases pressure within the portal vein that is transmitted back into the veins that drain from the gastrointestinal tract including those from the esophagus. The increased backward pressure from the portal vein causes the esophageal veins to dilate. A patient with hepatic failure demonstrates deterioration in handwriting and when asked on exam to hold his arm and hand out like a stop sign, involuntary flapping of the hand (asterixis) is observed. These symptoms are most likely due to: A. Intracranial hemorrhage. B. Sub clinical seizure. C. Alcohol withdrawal. D. Encephalopathy. - CORRECT ANSWER D. Encephalopathy is an anticipated complication of hepatic failure and is caused by high ammonia levels, which cause neurotoxicity. In failure, the liver loses its ability to normally metabolize and detoxify substances. Ammonia is produced by bacteria in the bowel and is a byproduct of protein metabolism. Normally, the liver metabolizes ammonia into urea for excretion. In liver failure, ammonia levels rise. When assessing the abdomen of a patient, the correct order of assessment techniques is: A. Palpation, percussion, auscultation, inspection. B. Inspection, palpation, percussion, auscultation. C. Inspection, auscultation, percussion, palpation. D. Percussion, palpation, auscultation, inspection. - CORRECT ANSWER C. When assessing the abdomen it is important to auscultate before performing percussion or palpation. The performance of palpation or percussion if done first can interfere with the auscultatory assessment. Stress ulceration in the stomach is common in critically ill patients. Stress ulcer prophylaxis is indicated in which of the following patients at highest risk for GI bleeding: Choose one A. Mechanical ventilation for more than 48 hours. B. History of GI ulceration or bleeding in the past year. C. ICU stay longer than 1 week. D. Coagulopathy. E. All of the above. - CORRECT ANSWER E. Two major risk factors for clinically important GI bleeding are mechanical ventilation for more than 48 hours and coagulopathy (defined as a platelet count <50,000, INR >1.5, or aPTT >2 times the control value). In addition, guidelines recommend stress ulcer prophylaxis in patients with a history of GI ulceration or bleeding within the past year, and two or more of the following risk factors: sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, and glucocorticoid therapy. Drugs used to prevent GI bleeding in critically ill patients include which of the following: A. Beta blockers and calcium channel blockers. B. Aldosterone blockers and beta blockers. C. Proton pump inhibitors (PPI) and histamine-2 receptor blockers (H2 blockers). D. ACE inhibitors and angiotensin receptor blockers (ARBs). - CORRECT ANSWER C. H2 blockers and PPI reduce gastric acid secretion. Examples of H2 blockers include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepsid), and nizatidine (Axid). Examples of PPI include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), and pantoprazole (Protonix). Other drugs that can be used include sucralfate (Carafate) which coats and protects the gastric mucosa without altering gastric acid secretion, and antacids which neutralize gastric acid to protect the gastric mucosa. ACE inhibitors prevent conversion of angiotensin I to angiotensin II and ARBs block angiotensin II at its receptor site. Both are used to treat heart failure and hypertension. Aldosterone blockers are used in heart failure to block aldosterone's effect on Na+ and water reabsorption by the kidney. Beta blockers and calcium channel blockers can be used to treat hypertension and angina. Beta blockers are indicated in heart failure as well. You are caring for a 44 year old male who is being admitted with acute upper GI bleeding. He is vomiting bright red blood, his skin is cold and clammy, BP is 86/52, heart rate is 120. You know that the main priority in his care right now is: A. Inserting an NG tube to decompress the stomach and assess rate of bleeding. B. Administering crystalloid IV fluids and/or blood products to prevent or treat hypovolemic shock. C. Administering an H2 blocker to decrease gastric acid production. D. Preparing him for endoscopy to locate the site of bleeding. - CORRECT ANSWER B. The most important immediate treatment of GI bleeding is maintaining adequate intravascular volume to prevent or manage hypovolemic shock. Hypotension due to hypovolemic shock can result in multiple organ damage. Two large bore IV lines should be inserted and crystalloid IV fluids (NS or lactated Ringers) should be started immediately. Blood should be obtained for type and cross matching for packed RBCs. Hemodynamic status should be monitored closely with frequent vital signs and possibly invasive monitoring with a CVP or pulmonary artery catheter. An NG tube can be inserted to monitor bleeding and help remove blood from the stomach, but this is not the first priority of care in this patient. An endoscopy is needed to identify the site of bleeding as soon as possible, but stabilizing hemodynamics is the most immediate priority. H2 blockers are used to decrease gastric acid production and prevent ulcers. They are not used as immediate therapy for GI bleeding. You are caring for a 64 year old man who is admitted with upper GI bleeding due to esophageal varices. This is his second admission for this problem in the past 5 weeks. He is vomiting bright red blood, skin is cool and jaundiced, and he is disoriented and lethargic. You know that esophageal varices are most commonly due to: A. Acute cholecystitis. B. Cirrhosis. C. Acute pancreatitis. D. Liver cancer. - CORRECT ANSWER B. Esophageal varices are engorged, tortuous veins in the esophagus that result from increased pressure in the portal veins (veins that drain from the stomach and intestines through the liver). The most common cause of esophageal varices is cirrhosis of the liver, which causes fibrosis and hardening of the liver that prevents blood from passing easily through the liver. Pressure rises in the portal veins and backs up into esophageal veins, causing engorgement that can lead to bleeding. Cirrhosis can be caused by several things, but the two most common causes in the US are alcoholic liver disease and hepatitis C. You are caring for a 64 year old man who is admitted with upper GI bleeding from esophageal varices secondary to alcoholic cirrhosis. This is his second admission for this problem in the past 5 weeks. He is vomiting a large amount of bright red blood, skin is cool and jaundiced, and he is disoriented and lethargic. His BP is 94/56, sinus tachycardia at 118, respirations 28 and shallow. Labs show Hct of 24%, Hgb of 6 gm/dL, PT is 30 seconds, aPTT is >45 seconds. He is receiving NS at 150 ml/hr and a unit of packed RBCs to manage hypotension. You anticipate which of the following therapies might be used in addition to fluids and blood replacement: A. FFP to replace clotting factors. B. Sengstaken-Blakemore tube insertion. C. Prophylactic antibiotics. D. All of the above. - CORRECT ANSWER D. Actively bleeding esophageal varices can be a life-threatening emergency if bleeding can't be controlled quickly. Hemodynamic support with fluids and RBCs is essential to prevent or treat hypovolemic shock. In addition, replacement of clotting factors with FFP or cryoprecipitate may be necessary when PT and aPTT are elevated (this is common in cirrhosis because the liver normally makes most clotting factors). Prophylactic antibiotics are recommended in patients with cirrhosis who present with upper GI bleeding because they reduce the incidence of infectious complications and may reduce mortality. Balloon tamponade of the varices with a Sengstaken-Blakemore tube (or a Minnesota tube) is a temporary measure that may be required if bleeding cannot be controlled any other way. Which of the following statements is/are accurate regarding care of a patient with a Sengstaken-Blakemore tube or Minnesota tube for tamponade of esophageal varices: A. The tube should be left in place for a minimum of 4 days to assure control of bleeding. B. The gastric balloon is inflated before the esophageal balloon and the esophageal balloon is deflated before the gastric balloon. C. The esophageal balloon should be inflated to 75 mmHg pressure to assure compression of varices. D. All of the above - CORRECT ANSWER B. The Sengstaken-Blakemore tube is a 3-lumen tube with a gastric balloon, an esophageal balloon, and a gastric aspiration port in the stomach. The Minnesota tube has all three of these lumens plus an esophageal aspiration port above the esophageal balloon. Both can be used as a temporary measure to control bleeding esophageal varices that are unresponsive to medical therapy. Once the tube is inserted, the gastric balloon is inflated first with 450 - 500 cc of air (after confirmation of placement in the stomach). Mild traction is applied at the point where the tube enters the nose; this pulls the gastric balloon against the gastroesophageal junction and may be enough to stop bleeding. If bleeding continues, then the esophageal balloon is inflated to 30-45 mmHg. The esophageal balloon should be deflated every few hours for about 5 minutes to prevent necrosis of esophageal tissue and to check for bleeding. The tube can be left in place for up to 48 hours. Once bleeding is controlled, the esophageal balloon is deflated by 5 mmHg every 3 hours or so until a pressure of 25 mmHg is attained; this pressure can be maintained for 12-24 hours. When the tube is removed, the esophageal balloon is deflated first, then the gastric balloon is deflated. The patient is usually intubated prior to placement of the tube to prevent airway obstruction. Scissors should be at the head of the bed and should accompany the patient if transfer is necessary so that the tube can be cut in the emergency situation of airway obstruction. This illustration shows placement of the tube. You are caring for a 24 year old female who was admitted with a suspected acetaminophen overdose. The most common serious complication of acetaminophen overdose is: A. Acute pancreatitis. B. Hemorrhagic stroke. C. Acute renal failure. D. Acute liver failure. - CORRECT ANSWER D. Acute liver failure is most often due to viral or toxin induced hepatitis. Acetaminophen poisoning is the most common cause of acute liver failure in the United States. Hepatitis B is the most common viral cause. Hepatitis A is the most common form of acute viral hepatitis, but it rarely causes acute liver failure. Other causes of acute liver failure include portal or hepatic vein thrombosis, prolonged liver ischemia, and sepsis. Excessive high doses of acetaminophen are metabolized to high levels of a toxic metabolite that causes hepatocellular necrosis. In addition, release of cytokines and other substances from damaged hepatocytes contributes to the spread of cellular damage. You are caring for a 24 year old female who was admitted following an acetaminophen overdose. She admits to swallowing approximately 50 tablets 2 hours ago but denies taking any other drugs. She is nauseated but alert, oriented, and has no other symptoms so far. Initial lab values for liver and renal function, electrolytes, and PT/aPTT are normal. Knowing the usual course of acetaminophen poisoning, you anticipate which of the following actions/treatments within the next two hours: A. Immediate intubation to prevent respiratory arrest. B. Administration of acetylcysteine as an antidote. C. Administration of phenytoin (Dilantin) for seizure prevention. D. Immediate dialysis to remove acetaminophen and prevent renal failure. - CORRECT ANSWER B. Acetaminophen overdose usually results in acute liver failure within 72 hours. Within the first 24 hours, patients are often asymptomatic or have nonspecific symptoms such as nausea, vomiting, diaphoresis, pallor, and lethargy; and liver function labs are normal unless there is preexisting liver disease. From 24 to 72 hours after ingestion, clinical and laboratory evidence of hepatotoxicity (and often nephrotoxicity) appear: elevated AST/ALT levels, prolonged PT, and elevated bilirubin. Liver function abnormalities peak from 72 to 96 hours after ingestion, and patients develop jaundice, confusion (hepatic encephalopathy), marked elevation in hepatic enzymes, elevated ammonia levels, and bleeding. GI decontamination with activated charcoal by mouth can be effective in patients who present within four hours of acute ingestion. Acetylcysteine is the antidote for acetaminophen poisoning and has the best outcome when given within 8 hours of ingestion. Serious hepatotoxicity is uncommon and death extremely rare if acetylcysteine is administered within eight hours following acetaminophen ingestion. Chronic liver failure does not occur as a result of acetaminophen overdose. Respiratory arrest and seizures would not occur until very late in the course of multiorgan dysfunction as a result of acetaminophen overdose. Acute renal failure occurs in 10 to 25 percent of patients with significant hepatotoxicity, and dialysis can be used to reduce acetaminophen levels if treatment with acetylcysteine is not successful. However, dialysis is not the initial treatment. Pharmacological treatment of bleeding gastric ulcers or gastritis can include all of the following EXCEPT: A. Nonsteroidal anti-inflammatory drugs (NSAIDS) to decrease gastric inflammation. B. Antibiotics to treat H. pylori infections. C. Histamine H2 blockers or proton pump inhibitors (PPI) to decrease acid production. D. Antacids or sucralfate to protect stomach mucosa. - CORRECT ANSWER A. Patients with gastric ulcers should avoid NSAIDs because they can contribute to development of ulcers by inhibiting prostaglandins. Stomach or duodenal ulcers are common side effects of long-term NSAID use. Histamine H2 blockers decrease stimulation of H2 receptors in gastric cells that are responsible for secretion of hydrochloric acid, resulting in a decrease in gastric acid secretion. PPIs totally block stomach acid secretion and are the most powerful drugs for treating peptic ulcer disease. Antacids neutralize stomach acid to decrease irritation and inflammation of gastric mucosa. Sucralfate coats the gastric mucosa to reduce its exposure to stomach acids. 80% to 90% of gastric ulcers are caused by infection with Heliobacter pylori (H. pylori) bacteria. Antibiotics used to treat H. pylori infections include tetracycline, amoxicillin, clarithromycin (Biaxin), and metronidazole (Flagyl). You receive a 42 year old male patient from the Emergency Department who is being admitted with acute pancreatitis. His blood pressure is 92/70, heart rate 100, respiratory rate 16, temperature 37.2 C. He is experiencing pain of 8/10 and continues to have nausea. Priority initial interventions in treating acute pancreatitis include all of the following EXCEPT: A. Pain management. B. NPO status to decrease pancreatic activity. C. Cardiac monitoring. D. Fluid resuscitation. - CORRECT ANSWER C. Initial priorities are aimed at decreasing the release of pancreatic enzymes by placing the patient on NPO status. Pain management is a priority to not only provide comfort but also assure the patient is able to participate in deep breathing activities to prevent pulmonary complications often associated with pancreatitis. Fluid resuscitation is needed secondary to third space shifting of fluids and the associated hypovolemic state. You receive a 42 year old male patient from the Emergency Department who is being admitted with suspected acute pancreatitis. You know the blood test most specific to acute pancreatitis is: A. Serum ammonia level. B. Urine amylase Level. C. Serum lipase Level. D. Serum amylase level. - CORRECT ANSWER C. Serum amylase level rises faster than serum lipase levels but serum lipase is more specific to the pancreas than serum amylase. Therefore, serum amylase is considered an early marker but serum lipase is a confirmatory marker when elevated 3 times normal. Urine amylase will often rise with pancreatitis but again, serum lipase is more specific to pancreatitis. Your 78 year old male patient with acute pancreatitis is ordered fluid resuscitation with 0.9% Normal Saline at 250cc per hour over 4 hours. This patient has a history of a significant myocardial infarction in the past. Over the next 4 hours your clinical assessment priority will be: A. Assessment of pain to assure he does not become overstressed and increase his myocardial demand. B. Monitor weight for signs of fluid overload. C. Assessment of lung sounds for signs of pulmonary edema. D. Assessment of extremities for signs of increasing peripheral edema. - CORRECT ANSWER C. With a past cardiac history of significant myocardial infarction the addition of large volumes of fluid can result in fluid overload and pulmonary edema if the patient has a reduced ejection fraction. Fluid resuscitation is important but large volumes of fluid in the cardiac patient require careful, frequent assessments. Many patients with acute pancreatitis already have edema secondary to the third spacing of fluids during the acute phase of pancreatitis. Therefore, peripheral edema and weight gain may be related to third spacing of fluid and not increased circulating volume. All patients with pancreatitis require careful pain management with the primary goal of assuring good respiratory effort to avoid pulmonary complications. Patients with pancreatitis often take small breaths due to the pain they are experiencing. Nutrition support is important in the patient with acute pancreatitis. You anticipate once the nausea and vomiting has subsided nutrition will be provided in the following manner: A. Soft, low fat diet. B. Continuous tube feedings with a nasojejunal tube. C. Total parental nutrition with no lipids. D. Clear liquid diet. - CORRECT ANSWER A. The newest literature supports feeding the patient as early as possible to prevent an empty bowel and the complications associated with lack of nutrition in the gut. Oral feedings are preferred over tube feedings or TPN if the patient is able to tolerate. Soft diet is recommended over clear liquids. A nasogastric (NG) tube was placed after you patient was intubated. You have medications to give the patient via the NG tube. Prior to the initial administration of any medication or feeding via the NG tube the nurse should: A. Verify NG tube placement by pH testing of the gastric secretions. B. Verify NG tube placement by chest X-ray. C. Verify NG tube placement by auscultating over the epigastric area while instilling a large air bolus into the epigastric area. D. Verify NG tube placement using a carbon dioxide detector. - CORRECT ANSWER B. The only reliable method for assessing tube placement after initial placement is with a chest x-ray. All other methods lack the reliability of the radiograph. Nursing interventions for the prevention of aspiration in patients with tube feedings include: A. Maintain endotracheal cuff pressure at > 30 cm H2O to prevent leakage of secretions around the endotracheal cuff. B. Providing adequate sedation so the patient is better able to tolerate the feedings. C. Assessing for tolerance of tube feedings every 8 hours. D. Elevation of the head of the bed to a level of 30-45 degrees during tube feedings. - CORRECT ANSWER D. Tube feeding tolerance should be evaluated every 4 hours. Sedation should be kept to the lowest level possible. Increased sedation decreases the cough and gag reflex and may interfere with the patients ability to handle secretions. Sedation may also slow gastric emptying. Endotracheal tube cuff pressure should be > 20 cm H2O to prevent leakage of gastric secretions around the endotracheal tube. Endotracheal tube cuff pressure be maintained at < 30 cm H2O to prevent tracheal injury. You are caring for a patient in the ICU who is intubated and on mechanical ventilation. The patient was admitted 26 hours ago with pneumonia. The patient is hemodynamically stable after initial treatment with fluids and antibiotics. The patient has bowel sounds present in all four quadrants. The intensive care physician arrives on the floor for daily rounds. What recommendations will be taken into consideration when making decisions about nutrition for the patient: A. Enteral nutrition is the preferred method for providing nutrition and should be started 24 to 48 hours after admission in patients who have been adequately fluid resuscitated. B. The patient should remain NPO for the first 72 hours from admission and then evaluated for the safe initiation of enteral feedings. C. Parental nutrition is preferred over enteral nutrition in patients admitted with an infectious process. D. Parental nutrition is recommended ov - CORRECT ANSWER A. If the critically ill ICU patient is hemodynamically stable with a functional gastrointestinal tract, then enteral nutrition (EN) is recommended over parental nutrition (PN). Patients who receive EN experience less septic morbidity and fewer infectious complications than patients who received PN. If the critically ill patient is adequately fluid resuscitated, then EN should be started within 24 to 48 hours following injury or admission to the ICU. Early EN is associated with a reduction in infectious complications and may reduce LOS. When caring for a patient admitted to the critical care unit with an acute illness accompanied by hypotension, the nurse recognizes the patient is at risk for developing the following that may predispose the patient to a gastrointestinal (GI) bleed: A. Stress ulcer. B. AV malformation. C. Mallory-Weiss tear. D. Esophageal varices. - CORRECT ANSWER A. Upper GI bleed is more common than lower GI bleed. Approximately 20 to 25% percent of patients who experience an upper GI bleed are already hospitalized. Ruptured esophageal varices, AV malformation, and Mallory-Weiss tear (longitudinal tear of the esophagus caused by forceful retching) can all cause upper GI bleeding. However, the most common cause of upper GI bleeding is a peptic ulcer. Peptic ulcers include both gastric and duodenal ulcers. Peptic ulcers occur when the normal protective mechanisms fail to work. Stress ulcers have the same etiology as peptic ulcers although they are typically limited to the stomach. They can develop within hours of admission to the hospital. Contributing factors include decreased mucosal blood flow leading to ischemia and degeneration of the mucosal lining. Once the protective lining is penetrated, gastric secretions autodigest the layers of the stomach. This leads to damage of the mucosal and submucosal layers. Damage can penetrate to the blood vessels and result in hemorrhage. The layer of the GI tract that is exposed to dietary intake and responsible for protecting the gut from erosion: A. Mucosa. B. Submucosa. C. Serosa. D. Muscularis. - CORRECT ANSWER A. The layers of the GI tract from most internal to external are the mucosa, submucosa, muscularis, and serosa. The serosa is frequently contiguous with the peritoneum. The mucosal layer includes the mucosal epithelial cells which secrete bicarbonate and help maintain the pH of the gut. . The critically ill patient with no nutritional intake will develop nutritional deficiencies and malnutrition. Inactivity of the GI tract can result in: A. Profound diarrhea. B. Bowel obstruction. C. Increased rate of infection. D. Gastrointestinal bleeding. - CORRECT ANSWER C. Normal bowel function prevents the millions of bacteria normally circulating In the GI tract from colonizing. Lack of GI motility allows bacteria to accumulate. Critical illness can result in the breakdown of the normal barriers in the gut. With normal defenses down, the accumulated bacteria can translocate to the lymphatic system placing the patient at a higher risk of infection. A common culprit of recurrent peptic ulcer disease is: A. Haemophilus influenza. B. Klebsiella pneumoniea. C. Streptococcus pneumoniae. D. Helicobacter pylori. - CORRECT ANSWER D. Helicobacter is the bacterial agent that is been identified as the most common cause of recurrent peptic ulcer disease. Streptococcus pneumoniae is a very common cause of community acquired pneumonia. Haemophilus influenza is a cause of community acquired pneumonia often seen in smokers. Klebsiella pneumoniae is a cause of community acquired pneumonia often seen in those with chronic alcoholism. Strategies that can be used in the treatment of upper GI hemorrhage to help control bleeding include of the following except: A. Endoscopy with sclerotherapy. B. Vasopressin. C. Octreotide (sandostatin). D. Gastric lavage. - CORRECT ANSWER D. The use of gastric lavage in upper GI bleeding is aimed at emptying the upper GI tract of blood and to monitor the bleeding but is not beneficial in treating the bleeding. Octreotide (Sandostatin) reduces splanchnic blood flow and also decreases the secretion of gastric acid and reduces GI motility. Endoscopy is used for diagnosis of GI bleeding. The use of sclerotherapy involves the injection of an agent around and into the bleeding vessels. For this procedure epinephrine is often used. Vasopressin helps control bleeding by causing vasoconstriction of the arterioles in the splanchnic bed. It also decreases portal venous pressure. When caring for a patient with acute pancreatitis who is hypotensive the nurse knows the primary intervention is going to be: A. Vasopressors to counteract the effects of alpha blockage. B. Inotropes to increase cardiac output. C. Aggressive fluid resuscitation. D. Emergent surgery. - CORRECT ANSWER C. In acute pancreatitis hypoalbuminemia is often present which leads to a decrease in oncotic pressure. In conjunction with severe inflammation this can lead to large amounts of fluid leaking into the peritoneal or even retroperitoneal space. Aggressive fluid administration to maintain adequate preload is a priority treatment consideration. Cardiac output is adversely affected in acute pancreatitis due to a deficit in preload and not due to a contractility problem. Vasopressors may be needed if fluid resuscitation is not effective in achieving an adequate mean arterial pressure. However, fluid should be used first because the physiological alterations in acute pancreatitis result in a reduction of preload. Pancreatitis is managed medically except in rare cases of necrotizing pancreatitis. The most common causes of acute pancreatitis are: A. Cholelithiasis and heavy alcohol use. B. Hepatitis and stress ulcers. C. Stress ulcers and cholelithiasis. D. Heavy alcohol use and hepatitis. - CORRECT ANSWER A.Pancreatitis occurs when pancreatic enzymes are activated while still in the pancreas and the enzymes autodigest the pancreas. This occurs as a result of an obstruction. Gallstones and heavy alcohol intake are the two most common causes. Gallstones located in the distal common bile duct can block the pancreatic duct. This can lead to a reflux of bile into the pancreas. When gallstones are the etiology the serum alanine aminotransferase (ALT) is elevated. Alcohol use is the most common cause of pancreatitis. Alcohol can increase the protein content of pancreatic fluid and therefore predispose the patient to blockages within the ducts. Alcohol may also cause spasm of the sphincter of Oddi which increases pressure within the ducts. The patient with liver failure is likely to have which of the following lab values: A. Normal PT, hypoglycemia, hypokalemia, hyponatremia, normal AST and ALT, normal albumin, elevated alkaline phosphatase, reduced bilirubin. B. Prolonged PT, hypokalemia, hypoglycemia, low albumin level, elevated AST and ALT, elevated alkaline phosphatase, elevated bilirubin. C. Prolonged PT, hyperkalemia, hyperglycemia, elevated AST and ALT, low bilirubin, low alkaline phosphatase. D. Hypoglycemia, hyperkalemia, prolonged PT, elevated albumin level, elevated AST and ALT, reduced alkaline phosphatase, reduced bilirubin. - CORRECT ANSWER B. A variety of abnormal lab values can occur with liver dysfunction. The most common liver function tests used in clinical practice include the serum aminotransferases (AST, ALT), bilirubin, alkaline phosphatase, albumin, and prothrombin time. Tests that detect injury to hepatocytes include AST and ALT levels, which increase in liver dysfunction. Tests that measure the liver's ability to clear substances from the circulation include serum measurements of bilirubin, bile acids, and other substances whose levels increase when the liver is unable to clear them from the circulation. Tests of the liver's ability to synthesize proteins and clotting factors include measurement of serum albumin and the prothrombin time. Albumin is one of many proteins synthesized in the liver; albumin levels are low in liver disease. The PT is prolonged in liver failure because the liver is unable to produce clotting factors. The most common electrolyte disturbances in liver failure are hypokalemia, hyponatremia, and hypophosphatemia. Hypoglycemia is common in liver failure due to depletion of hepatic glycogen stores and impaired ability of the liver to convert glycogen to glucose. A patient with acute liver failure is prone to all of the following complications except: A. Infection and sepsis. B. Ischemic stroke and bowel infarction. C. Renal failure and GI bleeding. D. Cerebral edema and increased intracranial pressure. - CORRECT ANSWER B. Ischemic stroke and bowel infarction would most likely occur as a result of thrombus formation or embolization. In liver failure, coagulation proteins and clotting factors are not produced by the liver, resulting in an increased risk of bleeding rather than a risk of clotting. Patients with acute liver failure are susceptible to encephalopathy, cerebral edema, renal failure, hypoglycemia, metabolic acidosis, sepsis, coagulopathy, and multiorgan failure. Encephalopathy can result from increased ammonia levels and other metabolic abnormalities that occur with liver failure. Hepatorenal syndrome is a form of renal failure that occurs with severe liver disease and is thought to be due to portal hypertension that causes renal vasoconstriction and decreased renal perfusion. Patients with liver failure often develop coagulopathy and bleed due to the diminished capacity of the liver to synthesize coagulation factors. The most common site of bleeding is the gastrointestinal tract. An increase in blood-brain barrier permeability occurs in severe liver failure for unknown reasons and can lead to exposure of the brain to ammonia and other neurotoxic substances that can result in cerebral edema. Cerebral edema often leads to an increase in ICP. Patients with liver failure are at increased risk of infection and sepsis related to a variety of immunologic dysfunctions, including complement deficiency, increased gut bacterial translocation, and white blood cell dysfunction. The most common sites of infection are the respiratory and urinary tracts and blood. Which of the following assessment findings would increase your concern for a small bowel obstruction: A. Abdominal pain with diffuse tenderness, rigid boardlike abdomen, absent bowel sounds. B. Hematochezia, tachycardia, narrow pulse pressure, hyperactive bowel sounds. C. Hematemesis, normal bowel sounds to hyperactive bowel sounds, tachycardia, narrow pulse pressure. D. High pitched bowel sounds, crampy abdomen, distended, mildly tender abdomen. - CORRECT ANSWER D. Small bowel obstruction often presents with: crampy abdominal pain along with high pitched bowel sounds. The abdomen may be distended and mildly tender. Gastrointestinal perforations present with: abdominal pain with diffuse tenderness, a rigid boardlike abdomen, and absent bowel sounds. Hematochezia is bright red blood from the rectum and presents as gastrointestinal bleeding. Hematemesis is bright red blood or coffee ground emesis, also present with gastrointestinal bleeding. Critically ill patients on mechanical ventilation and those receiving enteral feedings are at high risk for aspiration. What practices are recommended to reduce the risk of aspiration: A. Assess placement of feeding tubes every 12 hours. B. Maintain head of bed elevation at 90 degrees at all times. C. Use liberal sedation to prevent coughing and the risk of aspiration. D. Avoid bolus tube feedings in patients at high risk for aspiration. - CORRECT ANSWER D. The American Association of Critical Care Nurses has published a Practice Alert for the prevention of aspiration. According to this document, strategies to reduce the risk of aspiration in patients on mechanical ventilation and / or patients receiving enteral tube feedings include the following: 1) Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated, 2) Use sedatives as sparingly as feasible, 3) For tube-fed patients, assess placement of the feeding tube at 4-hour intervals, 4) For patients receiving gastric tube feedings, assess for gastrointestinal intolerance to the feedings at 4-hour intervals, 5) For tube-fed patients, avoid bolus feedings in those at high risk for aspiration, 6) Consult with provider about obtaining a swallowing assessment before oral feedings are started for recently extubated patients who have experienced prolonged intubation, and 7) Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is deflated. When auscultating for bowel sounds the nurse knows the following is true: A. Auscultation should only occur after a full assessment for abnormalities through palpation. B. If unable to appreciate bowel sounds the assessment should reoccur after eating since this will increase peristalsis. C. The bell of the stethoscope is used to hear the majority of bowel sounds. D. Auscultate for a full 5 minutes before documenting the absence of bowel sounds. - CORRECT ANSWER D. Bowel sounds normally occur at a rate of 5-15 per minute. Hypoactive bowels sounds occur at a slower rate. It is recommended that full opportunity is provided to assure the absence of bowel sounds. The absence of bowel sounds is a reportable finding by the nurse. Auscultation precedes palpation. A full assessment of the reason for absent bowel sounds should be completed prior to feeding a patient. The bell of the stethoscope is used for low pitched sounds and the diaphragm of the stethoscope for high pitched sounds. Bowel sounds are more often high pitched than low pitched. Intra-abdominal hypertension (IAH) is defined as: A. Sustained or repeated pathological increase in intra-abdominal pressure that is greater than or equal to 12 mm Hg. B. Intermittent or sustained pathological increase in intra-abdominal pressure increase above 5 mm Hg. C. Intra-abdominal pressure great enough to cause compression on abdominal organs and result in abdominal compartment syndrome. D. Sustain intra-abdominal pressure from any cause that is greater than or equal to 8 mmHg. - CORRECT ANSWER A. Normal IAP is 0 mm Hg with some fluctuation up to 5 mm Hg (some resources support 7 mm Hg) being within normal limits. Many things can result in a temporary increase in IAP such as coughing and sneezing. Situations such as morbid obesity can result in chronic elevation of IAP. Chronic elevations are not associated with the effects of IAH that occurs in the critically ill patients such as abdominal compartment syndrome (ACS). ACS does not usually occur until IAP rises to 20 mm Hg or higher. All of the following put the patient at risk for the development of intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) EXCEPT: A. Increased abdominal wall compliance. B. Increased peritoneal cavity contents. C. Massive fluid resuscitation. D. Increased intestinal intraluminal contents that may occur with such situations as an ileus. - CORRECT ANSWER A. Decreased abdominal wall compliance can cause an increase in IAH and ACS. Situations that can decrease intra-abdominal wall compliance include acute respiratory failure with increased intrathoracic pressure, prone position, abdominal surgery with primary fascial or tight closure. Gastroparesis (delayed gastric emptying), ileus and colonic pseudo obstruction can all result in increased intestinal intraluminal contents. Increased peritoneal cavity contents occurs with hemoperitoneum, pneumoperitoneum, or ascites. Massive fluid resuscitation or capillary leak can may also result in IAH and ACS. Some of the most common situations where this occurs includes: massive transfusions (> 10 Units/24 hours), massive fluid resuscitations (>5 liters/24 hours), pancreatitis, sepsis, and burns. The abdominal perfusion pressure (APP) should be maintained at more than 50-60 mm Hg to assure adequate perfusion of the abdominal organs. Abdominal perfusion pressure is determined by the following formula: A. APP = MAP (mean arterial pressure) + IAP (intra-abdominal pressure). APP=MAP+IAP B. APP = IAP (intra-abdominal pressure) + MAP (mean arterial pressure). APP=IAP-MAP C. APP = MAP (mean arterial pressure) - IAP (intra-abdominal pressure). APP=MAP-IAP D. APP = IAP (intra-abdominal pressure) - MAP (mean arterial pressure). APP=IAP-MAP - CORRECT ANSWER C. When the IAP, usually measured as bladder pressure, is high it is difficult to maintain an adequate APP. Normal APP is greater than 50-60 mm Hg. Normal IAP is 0-5 mm Hg. Intra-abdominal hypertension (IAH) occurs with a sustained or repeated pathologic elevation of IAP > or equal to 12 mm Hg. Abdominal compartment syndrome (ACS) occurs with an IAP of greater than or equal to 20 mm Hg. Therefore, a MAP of 70 mm Hg - an IAP of 5 mm Hg will result in a normal APP of 65 mm Hg. If the MAP is 70 mm Hg and the IAP is 25 mm Hg (Grade III IAH) the APP would be 45 mm Hg putting the abdominal organs at risk for compromised perfusion. When measuring intra-abdominal pressure (IAP) via an indwelling urinary bladder catheter the following should occur to assure accurate assessment and readings: A. IAP should be measured at end inspiration. B. IAP should be expressed in centimeters of water since it is reflective of the bladder pressure. C. The transducer should be leveled and zeroed at the level of the umbilicus midway between the umbilicus and the spine. D. IAP should be measured with the patient supine. - CORRECT ANSWER D. The transducer should be leveled and zeroed at the iliac crest in the midaxillary line. IAP pressure should be measured at the end of expiration. IAP should be expressed in mm Hg keeping in mind that 1 mm Hg is equal to 1.36 cm H2O. Nursing interventions that may be used to help maintain or decrease intra-abdominal pressure include: A. Monitor fluid balance assuring there is a positive fluid balance to avoid dehydrating the bowel and leading to constipation. B. Assess for bowel impaction every 48 hours in the paralyzed, unresponsive, or sedated patient. C. Elevate the head of the bed greater than 30 degrees. D. Evacuate the bowel of its contents. - CORRECT ANSWER D. There are many nursing interventions that can help in keeping IAP normal or decreasing it in those with elevated pressures. Decreasing intraluminal contents, most specifically, bowel contents is important. In line with this is assessing the paralyzed, unresponsive, or sedated patient daily for impaction. To increase abdominal wall compliance (decreases IAP) avoid the prone position and do not elevated the HOB > 20 degrees. This HOB elevation recommendation is in conflict with ventilator protocols that recommend the HOB be elevated > 30 degrees. Some sources recommend placing the ventilated patient with increased IAP in Trendelenburg position which supports head elevation but does not have a significant impact on IAP as it eliminates the bend at the level of the groin. Fluid balance should be equal or negative. Positive fluid balance is associated with an increase in IAP. Other nursing measures include carefully monitoring tube feedings and residuals, assuring rectal and nasogastric tubes are patent, and if the patient is able to eat avoid gas producing foods. Gastric lavage, while not used routinely, may be used in gastrointestinal bleeding for all of the following reasons EXCEPT: A. To improve visualization of the gastric fundus in preparation for endoscopy or endoscopic treatments. B. To slow or stop the gastrointestinal bleeding. C. To clear the stomach of blood or clots. D. To identify the severity of the bleeding. - CORRECT ANSWER B. Gastric lavage in GI bleeding has not been found to stop the GI bleeding. It is helpful in removing blood and clots from the stomach. This can help in determining the source of the bleeding as well as improve visualization of the gastric fundus in preparation for endoscopy. The presence of large amounts of bright red blood in the aspirate could indicate the need for urgent endoscopy. Which of the following may occur during insertion of the lavage tube prior to gastric lavage: A. Uncontrolled hypertension. B. Tachycardias. C. Tamponade of esophageal varices. D. Brady dysrhythmias. - CORRECT ANSWER D. Insertion of a gastric lavage tube can cause stimulation of the parasympathetic nervous systems resulting in bradydysrhythmias. This effect is usually transient, but further tube insertion should be halted until the dysrhythmia resolves. Hypotension is more often a complication than tachycardia. Insertion of a tube for gastric lavage in a patient with suspected esophageal varices needs to be carefully considered as worsening bleeding can occur. The risk and benefits of the tube need to be evaluated before putting the patient at increased risk from tube insertion. Your patient has been admitted with liver failure. Which of the following laboratory findings is the most likely explanation for the ascites and edema the patient is demonstrating: A. Elevated AST (Aspartate Aminotransferase). B. Reduced albumin level. C. Reduced ALT (Alanine Aminotransferase). D. Elevated total bilirubin. - CORRECT ANSWER B. Protein consists of albumin and globulins. Albumin is the major protein in the serum and responsible for colloidal osmotic pressure. Colloidal osmotic pressure, is the osmotic pull determined by the number of plasma colloids or solutes that are unable to diffuse through a membrane. These plasma colloids, such as albumin, encourage the process of osmosis and draw solvents (water) to them. Oncotic (pulling) pressure is greater at the venous end of the capillary than hydrostatic pressure; therefore, the net result is that fluids are pulled into the capillary at the venous end of the capillary. Patients will low albumin levels have low colloidal osmotic pressure do not have the ability to pull fluids back in at the venous end of the capillary and fluid leaks into the interstitial spaces and ascites and edema occurs. Total protein levels would be low in this population as well. AST and ALT are markers of hepatocyte injury. Bilirubin results from the breakdown of products by the liver - most specifically hemoglobin. Most bilirubin is conjugated by the liver and rapidly excreted into bile and removed from the body through the gut. Elevated levels of conjugated bilirubin indicate liver disease. Elevated unconjugated bilirubin levels rarely indicate liver disease. In acute illness where there is no nutritional intake, cell atrophy of the small bowel can occur within 72 hours. The nurse recognizes that cell atrophy of the small bowel has the potential to lead to sepsis due to which mechanism: A. Translocation of bacteria. B. Profound diarrhea. C. Bowel obstruction. D. Loss of white blood cells with atrophied cells. - CORRECT ANSWER A. Cell atrophy is a major factor in the translocation of bacteria in acute illness. This translocation of bacteria places the patient at great risk for sepsis and even multiple organ dysfunction syndrome (MODS). Early feeding (within 48 hours when possible) using the GI tract is an important strategy in preventing the translocation of bacteria. Bile facilitates digestion of fats and contains cholesterol which is excreted in the feces. Bile is made by which organ? A. Pancreas. B. Liver. C. Stomach. D. Gall bladder. - CORRECT ANSWER B. Bile is synthesized in the liver and secreted into hepatic ducts which take it to the gallbladder for storage. Bile is released from the gallbladder into the duodenum through the common bile duct to aid in the digestion of fats. Some digestive enzymes are secreted by which organ? A. Stomach. B. Liver. C. Pancreas. D. Gall bladder. - CORRECT ANSWER C. The pancreas is both an endocrine and an exocrine organ. Its endocrine function is to make hormones (primarily insulin) and secrete them directly into the blood. Its exocrine function is to make inactive precursors of several digestive enzymes and store them until they are needed to digest a meal. These inactive enzymes are released into pancreatic ducts which transport them into the duodenum where they are activated to aid in digestion of carbohydrates, fats, and proteins. Storing these enzymes in their inactive form prevents them from auto digesting the pancreas. Premature activation of enzymes within the pancreas causes acute pancreatitis. The pathogenesis of acute pancreatitis is not fully understood, but gallstones and chronic alcohol abuse are the most common causes in the United States. A patient with liver failure due to severe hepatitis or advanced cirrhosis who develops mental status changes and other neurologic abnormalities most likely has: A. Hemorrhagic stroke. B. Hepatorenal syndrome. C. Hepatic encephalopathy. D. Alzheimer's dementia. - CORRECT ANSWER C. Hepatic encephalopathy (HE, also called portosystemic encephalopathy [PSE]) describes the potentially reversible neuropsychiatric abnormalities seen in patients with advanced liver dysfunction and implies that altered brain function is due to metabolic abnormalities that occur as a consequence of severe liver failure. In addition to the abnormal lab values seen in severe liver failure (hyponatremia, hypokalemia, hypoglycemia, elevated PT and liver enzymes), ammonia level is elevated in hepatic encephalopathy due to inability of the liver to clear ammonia and prevent its entry into the circulation. Ammonia is a neurotoxin that is produced in the gut and thought to be responsible for many of the neurologic signs seen in HE. Physical findings may include muscle wasting, jaundice, ascites, palmar erythema (reddening of the palms often associated with portal hypertension), edema, spider telangiectasia's (tiny red veins most prominent on the nose and cheeks due to venous hypertension). Mental status changes can range from mild confusion and slurred speech in the early stages of HE to deep coma in more advanced stages. You are caring for a patient with acute liver failure and hepatic encephalopathy due to Hepatitis B. You anticipate which of the following therapies might be appropriate for this patient? A. Administration of lactulose either orally or rectally. B. Referral for liver transplant evaluation. C. Administration of neomycin. D. All of the above. - CORRECT ANSWER D. Elevated ammonia levels are thought to contribute to hepatic encephalopathy. Ammonia is produced by bacteria in the gut and enters the circulation via the portal vein. Normally the liver clears almost all of the portal vein ammonia and prevents it from entering the systemic circulation. Lactulose lowers blood ammonia levels by causing an acidic pH in the gut which inhibits the diffusion of ammonia into the blood and enhances diffusion of ammonia from the blood into the gut where it is converted to ammonium which is not absorbable. Neomycin or other antibiotics can be used to alter gut bacteria and prevent formation of ammonia. Any patient with acute liver failure, decompensated cirrhosis, or hepatocellular carcinoma is a potential candidate for liver transplantation. In the absence of liver transplantation, patients with acute liver failure either have a complete recovery of liver function or will die within days. Delay in gastric emptying can increase the potential for increased intra-abdominal pressure. Which of the following will delay gastric emptying? A. High lipid content of the chyme in the stomach. B. Increased consumption of food. C. Anxiety, sadness, hostility or pain. D. All of the above. - CORRECT ANSWER D. Gastric emptying is directly affected by the amount of contents in the stomach. The food bolus is called chyme as it reaches the pyloric sphincter. The duodenum must be ready and able to accept the chyme leaving the stomach. The more liquid the gastric contents the more rapid the process of gastric emptying. The lower portion of the stomach close to the pylorus is called the antrum. A high level of acidity in the antrum will contribute to a delay in gastric emptying. Pain, a common factor in hospitalized patients also contributes to delayed gastric emptying. Other emotional stressors such as anxiety, depression, or hostility also contribute to a delay in gastric emptying. Food usually stays in the stomach for 2 to 6 hours. You are caring for a patient who had bariatric surgery. You know that these patients are at particular risk for all of the following complications in the early post op period EXCEPT: A. Pulmonary embolus and DVT. B. Airway obstruction and oxygenation issues. C. Gastrointestinal leaks and sepsis. D. Coagulopathies and DIC. - CORRECT ANSWER D. Pulmonary embolism (PE) is the most common cause of mortality in the early post-op period after weight-loss surgery and is responsible for more than 50 percent of deaths. The most common risk factors associated with PE include severe venous stasis disease, severe obesity (BMI >60), and obesity-hypoventilation syndrome. Strategies for preventing PE and DVT include use of sequential compression devices, subcutaneous unfractionated or low molecular weight heparin, and early ambulation when possible. Ambulation is a particular challenge with extremely obese patients, and pain management is an important consideration when promoting ambulation. Airway obstruction and oxygenation problems are common because many of these patients have sleep apnea preoperatively which increases their risk postoperatively. Close monitoring of oxygenation and respiratory status and use of CPAP or BiPAP machines help minimize the risk. A gastrointestinal leak can occur at sites of anastomosis and result in bleeding or leaking of gastric contents into the peritoneal space. If not discovered early, a leak can result in sepsis. Most leaks occur early in the first week after surgery but can occur up to a month after the operation. Signs a symptoms that can indicate a leak include fever, tachycardia, tachypnea, and abdominal or left shoulder pain. Coagulopathies and DIC are not particularly associated with this type of surgery, although DIC could occur in association with sepsis as a result of the inflammatory response. Clotting factors are made in the liver, and bariatric procedures do not alter liver anatomy or function. Your patient had abdominal surgery to repair a perforated bowel. He is very ill and on a ventilator, receiving IV antibiotics and fluids. He is sedated and on pain medication. Over the past few hours his heart rate has increased to 110, BP has dropped to 90/60, urine output has decreased to only 10 ml in the past hour. His lung sounds are mostly clear and equal bilaterally. His SaO2 has decreased to 90% even though his FIO2 has been increased, and the pressure alarm on the ventilator is alarming. His neck veins are distended, abdomen is tightly distended, and he is developing edema in his legs. These findings are most likely indicative of: A. Acute pulmonary embolism. B. Acute heart failure. C. Tension pneumothorax. D. Abdominal compartment syndrome. - CORRECT ANSWER D. Normal intra-abdominal pressure is 0-5 mmHg, and intra-abdominal hypertension (IAH) is defined as a sustained or repeated intra-abdominal pressure > 12 mmHg. Abdominal compartment syndrome (ACS) refers to organ dysfunction caused by intra-abdominal hypertension with an IAP of 20 mm Hg or greater. Risk factors for developing ACS include abdominal trauma, burns, liver transplant, abdominal conditions (massive ascites, bowel distension, abdominal surgery, intraperitoneal bleeding), and sepsis or other conditions requiring extensive fluid resuscitation. As abdominal pressure rises almost every organ system can be affected. The diaphragm is pushed upwards and affects both cardiac and pulmonary function. Intrathoracic pressure is increased, resulting in neck vein distension and increased airway pressures in ventilated patients. Cardiac output is decreased due to decreased venous return, resulting in tachycardia and hypotension. Renal function is decreased due to compression of the renal veins, and renal artery vasoconstriction is induced by the sympathetic nervous and renin-angiotensin systems, which are stimulated by the fall in cardiac output. The end result is progressive reduction in both glomerular perfusion and urine output. Mesenteric blood flow and intestinal mucosal perfusion are decreased, resulting in bowel edema, and liver function is decreased. Nearly all patients with ACS have a tensely distended abdomen. Other findings may include hypotension, tachycardia, an elevated jugular venous pressure, jugular venous distension, peripheral edema, abdominal tenderness, progressive oliguria, increased ventilatory requirements, or acute pulmonary decompensation. Measurement of bladder pressure has become the standard method to screen for IAH and ACS. The layer of the GI tract that is exposed to dietary intake is: A. Muscularis. B. Serosa. C. Mucosa. D. Submucosa. - CORRECT ANSWER C. The layers of the GI tract from most internal to external are the mucosa, submucosa, muscularis, and serosa. The serosa is frequently contiguous with the peritoneum. The gastroduodenal mucosa is coated by glycoprotein (GP) mucus. GP mucus forms a gel that prevents the back diffusion of acid and pepsin and helps maintain mucosal-luminal pH gradient. In the digestive system the pyloric valve is located: A. Between the small intestine and the colon. B. Between the lower esophagus and the stomach. C. Between the liver and the gall bladder. D. Between the stomach and the small intestine (duodenum). - CORRECT ANSWER D. The pylorus is at the end of the stomach. The pyloric antrum is open to the stomach. After the antrum is the pyloric canal which ends at the beginning of the duodenum (small intestine). There is a circular layer of fibers in the walls of the pyloric canal that creates a ring of smooth muscle called the pyloric sphincter (pyloric valve). The pyloric sphincter contracts to hold food in the stomach and allow time for the digestive juices in the stomach to break down the food into chyme before relaxing and allowing contents to move from the stomach to the small intestine. The pyloric sphincter also acts as a one way valve to prevent the regurgitation of food from the duodenum back to the stomach. A feeding tube is being placed at the bedside in a patient who is not fully alert. Immediately after insertion the patient is coughing and his respirations appear more labored. The appropriate response is: A. Check the patient's oxygen saturation to confirm that placement is correct. B. Remove the feeding tube and reattempt a new insertion. C. Insert an air bolus and listen over the epigastrium for proper placement. D. Call respiratory therapy to administer the patient's ordered breathing treatment since it is expected for this procedure to cause a mild bronchospasm. - CORRECT ANSWER B. The American Association of Critical Care Nurses has a Practice Alert for verification of feeding tube placement for blindly inserted feeding tubes. Coughing and dyspnea may occur when feeding tubes are mistakenly positioned in the airway, especially in patients with an impaired level of consciousness. If coughing or dyspnea are present after placement, the tube should be removed and new insertion attempted. Insertion of an air bolus and listening over the epigastrium is not a reliable method for assessing proper placement of a feeding tube. The ausculatory method is not a valid way to differentiate between respiratory and gastric placement or between gastric and small bowel placement. A patient's oxygen saturation will not provide information regarding placement of the feeding tube. A patient's oxygen saturation level could be either normal or low with the feeding tube either in the correct location or not in the correct location. When verifying proper placement of a blindly inserted feeding tube, what do you know to be true: A. Verify tube placement every 24 hours by observing for a change in length of the external portion of the feeding tube. B. Radiographic confirmation of tube placement is only needed prior to first use if capnography was not available during insertion. C. When there is doubt regarding the location of the feeding tube, the pH of the aspirate provides the definitive answer. D. Radiographic confirmation (interpreted by a radiologist) for correct placement of a blindly inserted tube is always needed prior to initial use for feedings or medications. - CORRECT ANSWER D. The American Association of Critical Care Nurses has a Practice Alert for verification of feeding tube placement for blindly inserted feeding tubes. Radiographic confirmation (interpreted by a radiologist) for correct placement of a blindly inserted tube is always needed prior to initial use for feedings or medications. After initial radiographic verification, the tube's exit site from the nose or mouth should be marked and documented. A carbon dioxide detector is helpful but is not adequately sensitive and specific to eliminate the need for a x-ray verification before initial use of a feeding tube. Also, when indicating that a tube is in the GI tract, a carbon dioxide detector cannot distinguish between the esophagus, stomach, or small bowel. Fasting gastric pH is usually 5 or less, even in patients receiving medications to inhibit acid. Respiratory secretions typically have a pH greater than 6. However, because gastric fluid occasionally has a high pH, this method cannot replace the need for an initial confirmatory X-ray or an X-ray when there is doubt regarding the tube's placement. Secretions from the small intestines usually have higher pH values (≥6) compared to gastric pH; therefore, pH testing is helpful in determining when a feeding tube has advanced from the stomach into the small bowel. The pH method has no benefit in detecting placement of a feeding tube in the esophagus. This is because esophageal fluid can be either swallowed saliva (alkaline) or refluxed gastric juices (acidic). The appearance of the aspirate can also not be used in place of the initial confirmatory X-ray. Tube location should be checked q 4 hours after feedings are started.