Author: nursedaisy98
ID: 256680
Card Set: Adult Health -
Gastrointestinal Updated: 4/20/2014
Tags: NCLEX RN
Description: Gastrointestinal
Show Answers:
1. 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?
1. Notify the health care provider (HCP).
2. Administer the prescribed pain medication.
3. Call and ask the operating room team to perform the surgery as soon as possible.
4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
1. Notify the health care provider (HCP)
2. A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse
is assessing the client's pain. What type of pain is consistent with this diagnosis?
1. Burning and aching, located in the left lower quadrant and radiating to the hip
2. Severe and unrelenting, located in the epigastric area and radiating to the back
3. Burning and aching, located in the epigastric area and radiating to the umbilicus
4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin
2. Severe and unrelenting, located in the epigastric area and radiating to the back
3. The nurse is assessing a client who is experiencing an acute episode of cholecystitis.
Where should the nurse anticipate the location of the pain?
1. Right lower quadrant, radiating to the back
2. Right lower quadrant, radiating to the umbilicus
3. Right upper quadrant, radiating to the left scapula and shoulder
4. Right upper quadrant, radiating to the right scapula and shoulder
4. Right upper quadrant, radiating to the right scapula and shoulder
4. A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and
"losing my taste for food." What instruction should the nurse give the client to provide
adequate nutrition?
1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only three large meals daily.
2. Increase intake of fluids, including juices.
5. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the
client for which expected assessment finding?
1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort
1. Malaise
,6. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for
this client? Select all that apply.
1. Administer stool softeners as prescribed.
2. Instruct the client to limit fluid intake to avoid urinary retention.
3. Instruct the client to avoid activities that will initiate vasovagal responses.
4. Encourage a high-fiber diet to promote bowel movements without straining.
5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
6. Help the client to a Fowler's position to place pressure on the rectal area and
decrease bleeding.
o 1. Administer stool softeners as prescribed.
o 4. Encourage a high-fiber diet to promote bowel movements without straining.
o 5. Apply cold packs to the anal-rectal area over the dressing until the packing is
removed.
7. The nurse is planning to teach a client with gastroesophageal reflux disease about
substances to avoid. Which items should the nurse include on this list? Select all that
apply.
1. Coffee
2. Chocolate
3. Peppermint
4. Nonfat milk
5. Fried chicken
6. Scrambled eggs
o 1. Coffee
o 2. Chocolate
o 3. Peppermint
o 5. Fried chicken
8. 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
9. The nurse has taught the client about an upcoming endoscopic retrograde
cholangiopancreatography procedure. The nurse determines that the client needs
further information if the client makes which statement?
1. "I know I must sign the consent form."
2. "I hope the throat spray keeps me from gagging."
3. "I'm glad I don't have to lie still for this procedure."
4. "I'm glad some IV medication will be given to relax me."
, 3. "I'm glad I don't have to lie still for this procedure."
10. The health care provider has determined that a client with hepatitis has contracted
the infection from contaminated food. The nurse understands that this client is most
likely experiencing what type of hepatitis?
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D
1. Hepatitis A
11. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors
the client, knowing that this client is at risk for which vitamin deficiency?
1. Vitamin A
2. Vitamin B12
3. Vitamin C
4. Vitamin E
2. Vitamin B 12
12. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes
that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which
nursing intervention is most appropriate?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the health care provider.
3. Document the findings.
13. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment
finding would most likely indicate perforation of the ulcer?
1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, boardlike abdomen
4. A rigid, boardlike abdomen
14. The nurse is caring for a client following a Billroth II procedure. Which
postoperative prescription should the nurse question and verify?
1. Leg exercises
2. Early ambulation
3. Irrigating the nasogastric tube
4. Coughing and deep-breathing exercises
3. Irrigating the nasogastric tube
15. The nurse is providing discharge instructions to a client following gastrectomy and
should instruct the client to take which measure to assist in preventing dumping
syndrome?
1. Ambulate following a meal.
, 2. Eat high-carbohydrate foods.
3. Limit the fluids taken with meals.
4. Sit in a high Fowler's position during meals.
3. Limit the fluids taken with meals.
16. The nurse is reviewing the prescription for a client admitted to the hospital with a
diagnosis of acute pancreatitis. Which interventions would the nurse expect to be
prescribed for the client? Select all that apply.
1. Administer antacids as prescribed.
2. Encourage coughing and deep breathing.
3. Administer anticholinergics as prescribed.
4. Give small, frequent high-calorie feedings.
5. Maintain the client in a supine and flat position.
6. Give opioid analgesics as prescribed for pain.
o 1. Administer antacids as prescribed.
o 2. Encourage coughing and deep breathing.
o 3. Administer anticholinergics as prescribed.
o 6. Give opioid analgesics as prescribed for pain.
17. The nurse is reviewing the record of a client with Crohn's disease. Which stool
characteristic should the nurse expect to note documented in the client's record?
1. Diarrhea
2. Chronic constipation
3. Constipation alternating with diarrhea
4. Stool constantly oozing from the rectum
1. Diarrhea
18. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes
that there is documentation of the presence of asterixis. How should the nurse assess
for its presence?
1. Dorsiflex the client's foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward.
3. Ask the client to extend the arms.
19. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that
the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for
this client?
1. Low-protein diet
2. High-protein diet
3. Moderate-fat diet
4. High-carbohydrate diet
ID: 256680
Card Set: Adult Health -
Gastrointestinal Updated: 4/20/2014
Tags: NCLEX RN
Description: Gastrointestinal
Show Answers:
1. 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?
1. Notify the health care provider (HCP).
2. Administer the prescribed pain medication.
3. Call and ask the operating room team to perform the surgery as soon as possible.
4. Reposition the client and apply a heating pad on the warm setting to the client's abdomen.
1. Notify the health care provider (HCP)
2. A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse
is assessing the client's pain. What type of pain is consistent with this diagnosis?
1. Burning and aching, located in the left lower quadrant and radiating to the hip
2. Severe and unrelenting, located in the epigastric area and radiating to the back
3. Burning and aching, located in the epigastric area and radiating to the umbilicus
4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin
2. Severe and unrelenting, located in the epigastric area and radiating to the back
3. The nurse is assessing a client who is experiencing an acute episode of cholecystitis.
Where should the nurse anticipate the location of the pain?
1. Right lower quadrant, radiating to the back
2. Right lower quadrant, radiating to the umbilicus
3. Right upper quadrant, radiating to the left scapula and shoulder
4. Right upper quadrant, radiating to the right scapula and shoulder
4. Right upper quadrant, radiating to the right scapula and shoulder
4. A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and
"losing my taste for food." What instruction should the nurse give the client to provide
adequate nutrition?
1. Select foods high in fat.
2. Increase intake of fluids, including juices.
3. Eat a good supper when anorexia is not as severe.
4. Eat less often, preferably only three large meals daily.
2. Increase intake of fluids, including juices.
5. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the
client for which expected assessment finding?
1. Malaise
2. Dark stools
3. Weight gain
4. Left upper quadrant discomfort
1. Malaise
,6. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for
this client? Select all that apply.
1. Administer stool softeners as prescribed.
2. Instruct the client to limit fluid intake to avoid urinary retention.
3. Instruct the client to avoid activities that will initiate vasovagal responses.
4. Encourage a high-fiber diet to promote bowel movements without straining.
5. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
6. Help the client to a Fowler's position to place pressure on the rectal area and
decrease bleeding.
o 1. Administer stool softeners as prescribed.
o 4. Encourage a high-fiber diet to promote bowel movements without straining.
o 5. Apply cold packs to the anal-rectal area over the dressing until the packing is
removed.
7. The nurse is planning to teach a client with gastroesophageal reflux disease about
substances to avoid. Which items should the nurse include on this list? Select all that
apply.
1. Coffee
2. Chocolate
3. Peppermint
4. Nonfat milk
5. Fried chicken
6. Scrambled eggs
o 1. Coffee
o 2. Chocolate
o 3. Peppermint
o 5. Fried chicken
8. 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
9. The nurse has taught the client about an upcoming endoscopic retrograde
cholangiopancreatography procedure. The nurse determines that the client needs
further information if the client makes which statement?
1. "I know I must sign the consent form."
2. "I hope the throat spray keeps me from gagging."
3. "I'm glad I don't have to lie still for this procedure."
4. "I'm glad some IV medication will be given to relax me."
, 3. "I'm glad I don't have to lie still for this procedure."
10. The health care provider has determined that a client with hepatitis has contracted
the infection from contaminated food. The nurse understands that this client is most
likely experiencing what type of hepatitis?
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D
1. Hepatitis A
11. The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors
the client, knowing that this client is at risk for which vitamin deficiency?
1. Vitamin A
2. Vitamin B12
3. Vitamin C
4. Vitamin E
2. Vitamin B 12
12. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes
that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which
nursing intervention is most appropriate?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the health care provider.
3. Document the findings.
13. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment
finding would most likely indicate perforation of the ulcer?
1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, boardlike abdomen
4. A rigid, boardlike abdomen
14. The nurse is caring for a client following a Billroth II procedure. Which
postoperative prescription should the nurse question and verify?
1. Leg exercises
2. Early ambulation
3. Irrigating the nasogastric tube
4. Coughing and deep-breathing exercises
3. Irrigating the nasogastric tube
15. The nurse is providing discharge instructions to a client following gastrectomy and
should instruct the client to take which measure to assist in preventing dumping
syndrome?
1. Ambulate following a meal.
, 2. Eat high-carbohydrate foods.
3. Limit the fluids taken with meals.
4. Sit in a high Fowler's position during meals.
3. Limit the fluids taken with meals.
16. The nurse is reviewing the prescription for a client admitted to the hospital with a
diagnosis of acute pancreatitis. Which interventions would the nurse expect to be
prescribed for the client? Select all that apply.
1. Administer antacids as prescribed.
2. Encourage coughing and deep breathing.
3. Administer anticholinergics as prescribed.
4. Give small, frequent high-calorie feedings.
5. Maintain the client in a supine and flat position.
6. Give opioid analgesics as prescribed for pain.
o 1. Administer antacids as prescribed.
o 2. Encourage coughing and deep breathing.
o 3. Administer anticholinergics as prescribed.
o 6. Give opioid analgesics as prescribed for pain.
17. The nurse is reviewing the record of a client with Crohn's disease. Which stool
characteristic should the nurse expect to note documented in the client's record?
1. Diarrhea
2. Chronic constipation
3. Constipation alternating with diarrhea
4. Stool constantly oozing from the rectum
1. Diarrhea
18. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes
that there is documentation of the presence of asterixis. How should the nurse assess
for its presence?
1. Dorsiflex the client's foot.
2. Measure the abdominal girth.
3. Ask the client to extend the arms.
4. Instruct the client to lean forward.
3. Ask the client to extend the arms.
19. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that
the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for
this client?
1. Low-protein diet
2. High-protein diet
3. Moderate-fat diet
4. High-carbohydrate diet
