Med Surg Gastrointestinal NCLEX Questions AND ANSWERS
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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.
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.
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
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
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
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 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
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.
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
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.
LATEST AND COMPLETE UPDATE WITH VERIFIED SOLUTIONS
GRADE A+ ASSURED PASS WITH INSTANT DOWNLOAD PDF.
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.
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.
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
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
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
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 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
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.
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
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.
