Med Surg Gastrointestinal NCLEX
Questions| RECENT
UPDATE|COMPREHENSIVE QUESTIONS
AND VERIFIED SOLUTIONS |GET IT 100%
ACCURATE!!
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
Questions| RECENT
UPDATE|COMPREHENSIVE QUESTIONS
AND VERIFIED SOLUTIONS |GET IT 100%
ACCURATE!!
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
