Med Surg Gastrointestinal NCLEX Questions Guide Graded A+
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.
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?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. C. Limit the fluids taken with meals.
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after
eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually
occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor,
palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount
of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to
assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric
emptying; and to take antispasmodics as prescribed.
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.
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?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. C. Limit the fluids taken with meals.
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after
eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually
occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor,
palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount
of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to
assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric
emptying; and to take antispasmodics as prescribed.
