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Med Surg Gastrointestinal NCLEX ||Verified Exam!!||
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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 - 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
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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 - 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
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development of pernicious anemia. Clients must increase
their intake of vitamin B12 by increasing consumption of
foods rich in this vitamin, such as nuts, organ meats, dried
beans, citrus fruits, green leafy vegetables, and yeast.
The nurse is monitoring a client with a diagnosis of peptic
ulcer. Which assessment finding would most likely indicate
perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - Answer-D. A rigid,
boardlike abdomen
Rationale:
Perforation of an ulcer is a surgical emergency and is
characterized by sudden, sharp, intolerable severe pain
beginning in the mid-epigastric area and spreading over
the abdomen, which becomes rigid and boardlike. Nausea
and vomiting may occur. Tachycardia may occur as
hypovolemic shock develops. Numbness in the legs is not
an associated finding.
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The nurse is caring for a client following a
gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and
verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - Answer-C.
Irrigating the nasogastric tube
Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal
remnant of the stomach is anastomosed to the proximal
jejunum. Patency of the nasogastric 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 prescribed by the health
care provider. In this situation, the nurse should clarify the
prescription. Options 1, 2, and 4 are appropriate
postoperative interventions.
Med Surg Gastrointestinal NCLEX ||Verified Exam!!||
Most Recent Exam Actual Complete Real Exam
Questions And Correct Answers (Verified Answers)
Already Graded A+ | Guaranteed Success!! Newest
Exam!!!
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 - 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
,2|Page
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 - 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
,3|Page
development of pernicious anemia. Clients must increase
their intake of vitamin B12 by increasing consumption of
foods rich in this vitamin, such as nuts, organ meats, dried
beans, citrus fruits, green leafy vegetables, and yeast.
The nurse is monitoring a client with a diagnosis of peptic
ulcer. Which assessment finding would most likely indicate
perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - Answer-D. A rigid,
boardlike abdomen
Rationale:
Perforation of an ulcer is a surgical emergency and is
characterized by sudden, sharp, intolerable severe pain
beginning in the mid-epigastric area and spreading over
the abdomen, which becomes rigid and boardlike. Nausea
and vomiting may occur. Tachycardia may occur as
hypovolemic shock develops. Numbness in the legs is not
an associated finding.
, 4|Page
The nurse is caring for a client following a
gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and
verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - Answer-C.
Irrigating the nasogastric tube
Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal
remnant of the stomach is anastomosed to the proximal
jejunum. Patency of the nasogastric 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 prescribed by the health
care provider. In this situation, the nurse should clarify the
prescription. Options 1, 2, and 4 are appropriate
postoperative interventions.
