Med Surg Gastrointestinal NCLEX Questions
With Correct Answers
The nurse is monitoring a client admitted to the hospital with a diagnosis of
| | | | | | | | | | | | |
appendicitis who is scheduled for surgery in 2 hours. The client begins to
| | | | | | | | | | | | |
complain of increased abdominal pain and begins to vomit. On assessment, the
| | | | | | | | | | | |
nurse notes that the abdomen is distended and bowel sounds are diminished.
| | | | | | | | | | | |
Which is the most appropriate nursing intervention?
| | | | | | |
A. Notify the health care provider (HCP).
| | | | | |
B. Administer the prescribed pain medication.
| | | | |
C. Call and ask the operating room team to perform surgery as soon as possible.
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D. Reposition the client and apply a heating pad on the warm setting to the
| | | | | | | | | | | | | |
client's abdomen. - CORRECT ANSWER✔✔-A. Notify the health care provider
| | | | | | | | | |
(HCP).
|
Rationale:
On the basis of the signs and symptoms presented in the question, the nurse
| | | | | | | | | | | | |
should suspect peritonitis and notify the HCP. Administering pain medication is
| | | | | | | | | | |
not an appropriate intervention. Heat should never be applied to the abdomen
| | | | | | | | | | | |
of a client with suspected appendicitis because of the risk of rupture. Scheduling
| | | | | | | | | | | | |
surgical time is not within the scope of nursing practice, although the HCP
| | | | | | | | | | | | |
probably would perform the surgery earlier than the prescheduled time.
| | | | | | | | | |
,A client has just had a hemorrhoidectomy. Which nursing interventions are
| | | | | | | | | |
appropriate for this client? Select all that apply.
| | | | | | | |
A. Administer stool softeners as prescribed.
| | | | |
B. Instruct the client to limit fluid intake to avoid urinary retention.
| | | | | | | | | | |
C. Encourage a high-fiber diet to promote bowel movements without straining.
| | | | | | | | | |
D. Apply cold packs to the anal-rectal area over the dressing until the packing is
| | | | | | | | | | | | | |
removed.
|
E. Help the client to a Fowler's position to place pressure on the rectal area and
| | | | | | | | | | | | | | |
decrease bleeding. - CORRECT ANSWER✔✔-A. Administer stool softeners as
| | | | | | | | |
prescribed.
|
C. Encourage a high-fiber diet to promote bowel movements without straining.
| | | | | | | | | |
D. Apply cold packs to the anal-rectal area over the dressing until the packing is
| | | | | | | | | | | | | |
removed.
|
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of
| | | | | | | | |
|pain and avoidance of bleeding and incision rupture. Stool softeners and a high-
| | | | | | | | | | | |
fiber diet will help the client to avoid straining, thereby reducing the chances of
| | | | | | | | | | | | |
|rupturing the incision. An ice pack will increase comfort and decrease bleeding.
| | | | | | | | | | |
|Options 2 and 5 are incorrect interventions.
| | | | | |
The nurse is planning to teach a client with gastroesophageal reflux disease
| | | | | | | | | | |
(GERD) about substances to avoid. Which items should the nurse include on this
| | | | | | | | | | | | |
list? Select all that apply.
| | | | |
,A. Coffee
|
B. Chocolate
|
C. Peppermint
|
D. Nonfat milk
| |
E. Fried chicken
| |
F. Scrambled eggs - CORRECT ANSWER✔✔-A. Coffee
| | | | | |
B. Chocolate
|
C. Peppermint
|
E. Fried chicken
| |
Rationale:
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the
| | | | | | | | | |
esophagus will increase reflux and exacerbate the symptoms of GERD and
| | | | | | | | | | |
therefore should be avoided. Aggravating substances include coffee, chocolate,
| | | | | | | | |
peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4
| | | | | | | | | | |
and 6 do not promote this effect.
| | | | | | |
A client has undergone esophagogastroduodenoscopy. The nurse should place
| | | | | | | |
highest priority on which item as part of the client's care plan?
| | | | | | | | | | | |
1. Monitoring the temperature
| | |
2. Monitoring complaints of heartburn
| | | |
3. Giving warm gargles for a sore throat
| | | | | | |
4. Assessing for the return of the gag reflex - CORRECT ANSWER✔✔-4. Assessing
| | | | | | | | | | | |
for the return of the gag reflex
| | | | | | |
, Rationale:
The nurse places highest priority on assessing for return of the gag reflex. This
| | | | | | | | | | | | |
assessment addresses the client's airway. The nurse also monitors the client's
| | | | | | | | | | |
vital signs and for a sudden increase in temperature, which could indicate
| | | | | | | | | | | |
perforation of the gastrointestinal tract. This complication would be accompanied
| | | | | | | | | |
by other signs as well, such as pain. Monitoring for sore throat and heartburn are
| | | | | | | | | | | | | | |
also important; however, the client's airway is the priority.
| | | | | | | | |
The nurse is providing dietary teaching for a client with a diagnosis of chronic
| | | | | | | | | | | | |
gastritis. The nurse instructs the client to include which foods rich in vitamin B12
| | | | | | | | | | | | | |
in the diet? Select all that apply.
| | | | | | |
A. Nuts |
B. Corn |
C. Liver
|
D. Apples
|
E. Lentils
|
F. Bananas - CORRECT ANSWER✔✔-A. Nuts
| | | | |
C. Liver
|
E. Lentils
|
Rationale:
Chronic gastritis causes deterioration and atrophy of the lining of the stomach,
| | | | | | | | | | |
leading to the loss of function of the parietal cells. The source of intrinsic factor is
| | | | | | | | | | | | | | | |
lost, which results in an inability to absorb vitamin B12, leading to development
| | | | | | | | | | | | |
With Correct Answers
The nurse is monitoring a client admitted to the hospital with a diagnosis of
| | | | | | | | | | | | |
appendicitis who is scheduled for surgery in 2 hours. The client begins to
| | | | | | | | | | | | |
complain of increased abdominal pain and begins to vomit. On assessment, the
| | | | | | | | | | | |
nurse notes that the abdomen is distended and bowel sounds are diminished.
| | | | | | | | | | | |
Which is the most appropriate nursing intervention?
| | | | | | |
A. Notify the health care provider (HCP).
| | | | | |
B. Administer the prescribed pain medication.
| | | | |
C. Call and ask the operating room team to perform surgery as soon as possible.
| | | | | | | | | | | | | |
D. Reposition the client and apply a heating pad on the warm setting to the
| | | | | | | | | | | | | |
client's abdomen. - CORRECT ANSWER✔✔-A. Notify the health care provider
| | | | | | | | | |
(HCP).
|
Rationale:
On the basis of the signs and symptoms presented in the question, the nurse
| | | | | | | | | | | | |
should suspect peritonitis and notify the HCP. Administering pain medication is
| | | | | | | | | | |
not an appropriate intervention. Heat should never be applied to the abdomen
| | | | | | | | | | | |
of a client with suspected appendicitis because of the risk of rupture. Scheduling
| | | | | | | | | | | | |
surgical time is not within the scope of nursing practice, although the HCP
| | | | | | | | | | | | |
probably would perform the surgery earlier than the prescheduled time.
| | | | | | | | | |
,A client has just had a hemorrhoidectomy. Which nursing interventions are
| | | | | | | | | |
appropriate for this client? Select all that apply.
| | | | | | | |
A. Administer stool softeners as prescribed.
| | | | |
B. Instruct the client to limit fluid intake to avoid urinary retention.
| | | | | | | | | | |
C. Encourage a high-fiber diet to promote bowel movements without straining.
| | | | | | | | | |
D. Apply cold packs to the anal-rectal area over the dressing until the packing is
| | | | | | | | | | | | | |
removed.
|
E. Help the client to a Fowler's position to place pressure on the rectal area and
| | | | | | | | | | | | | | |
decrease bleeding. - CORRECT ANSWER✔✔-A. Administer stool softeners as
| | | | | | | | |
prescribed.
|
C. Encourage a high-fiber diet to promote bowel movements without straining.
| | | | | | | | | |
D. Apply cold packs to the anal-rectal area over the dressing until the packing is
| | | | | | | | | | | | | |
removed.
|
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of
| | | | | | | | |
|pain and avoidance of bleeding and incision rupture. Stool softeners and a high-
| | | | | | | | | | | |
fiber diet will help the client to avoid straining, thereby reducing the chances of
| | | | | | | | | | | | |
|rupturing the incision. An ice pack will increase comfort and decrease bleeding.
| | | | | | | | | | |
|Options 2 and 5 are incorrect interventions.
| | | | | |
The nurse is planning to teach a client with gastroesophageal reflux disease
| | | | | | | | | | |
(GERD) about substances to avoid. Which items should the nurse include on this
| | | | | | | | | | | | |
list? Select all that apply.
| | | | |
,A. Coffee
|
B. Chocolate
|
C. Peppermint
|
D. Nonfat milk
| |
E. Fried chicken
| |
F. Scrambled eggs - CORRECT ANSWER✔✔-A. Coffee
| | | | | |
B. Chocolate
|
C. Peppermint
|
E. Fried chicken
| |
Rationale:
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the
| | | | | | | | | |
esophagus will increase reflux and exacerbate the symptoms of GERD and
| | | | | | | | | | |
therefore should be avoided. Aggravating substances include coffee, chocolate,
| | | | | | | | |
peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4
| | | | | | | | | | |
and 6 do not promote this effect.
| | | | | | |
A client has undergone esophagogastroduodenoscopy. The nurse should place
| | | | | | | |
highest priority on which item as part of the client's care plan?
| | | | | | | | | | | |
1. Monitoring the temperature
| | |
2. Monitoring complaints of heartburn
| | | |
3. Giving warm gargles for a sore throat
| | | | | | |
4. Assessing for the return of the gag reflex - CORRECT ANSWER✔✔-4. Assessing
| | | | | | | | | | | |
for the return of the gag reflex
| | | | | | |
, Rationale:
The nurse places highest priority on assessing for return of the gag reflex. This
| | | | | | | | | | | | |
assessment addresses the client's airway. The nurse also monitors the client's
| | | | | | | | | | |
vital signs and for a sudden increase in temperature, which could indicate
| | | | | | | | | | | |
perforation of the gastrointestinal tract. This complication would be accompanied
| | | | | | | | | |
by other signs as well, such as pain. Monitoring for sore throat and heartburn are
| | | | | | | | | | | | | | |
also important; however, the client's airway is the priority.
| | | | | | | | |
The nurse is providing dietary teaching for a client with a diagnosis of chronic
| | | | | | | | | | | | |
gastritis. The nurse instructs the client to include which foods rich in vitamin B12
| | | | | | | | | | | | | |
in the diet? Select all that apply.
| | | | | | |
A. Nuts |
B. Corn |
C. Liver
|
D. Apples
|
E. Lentils
|
F. Bananas - CORRECT ANSWER✔✔-A. Nuts
| | | | |
C. Liver
|
E. Lentils
|
Rationale:
Chronic gastritis causes deterioration and atrophy of the lining of the stomach,
| | | | | | | | | | |
leading to the loss of function of the parietal cells. The source of intrinsic factor is
| | | | | | | | | | | | | | | |
lost, which results in an inability to absorb vitamin B12, leading to development
| | | | | | | | | | | | |
