ATI MED SURG GASTROINTESTINAL LATEST ACTUAL EXAM
TEST BANK
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. - ANSWER: 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. - ANSWER: 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 - ANSWER: 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 - 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 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 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.
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.
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. - ANSWER: 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 providing discharge teaching for a client with newly diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - ANSWER: A. "I
should increase the fiber in my diet."
Rationale:
Crohn's disease is an inflammatory disease that can occur anywhere in the
gastrointestinal tract but most often affects the terminal ileum and leads to
thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is
characterized by exacerbations and remissions. If stress increases the symptoms of
the disease, the client is taught stress management techniques and may require
additional counseling. The client is taught to avoid gastrointestinal stimulants
containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber
diet may be prescribed, especially during periods of exacerbation.
The nurse is doing an admission assessment on a client with a history of duodenal
ulcer. To determine whether the problem is currently active, the nurse should assess
the client for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
C. Pain relieved by food intake
D. Pain radiating down the right arm - ANSWER: C. Pain relieved by food intake
Rationale:
TEST BANK
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. - ANSWER: 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. - ANSWER: 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 - ANSWER: 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 - 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 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 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.
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.
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. - ANSWER: 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 providing discharge teaching for a client with newly diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." - ANSWER: A. "I
should increase the fiber in my diet."
Rationale:
Crohn's disease is an inflammatory disease that can occur anywhere in the
gastrointestinal tract but most often affects the terminal ileum and leads to
thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses. It is
characterized by exacerbations and remissions. If stress increases the symptoms of
the disease, the client is taught stress management techniques and may require
additional counseling. The client is taught to avoid gastrointestinal stimulants
containing caffeine and to follow a high-calorie and high-protein diet. A low-fiber
diet may be prescribed, especially during periods of exacerbation.
The nurse is doing an admission assessment on a client with a history of duodenal
ulcer. To determine whether the problem is currently active, the nurse should assess
the client for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
C. Pain relieved by food intake
D. Pain radiating down the right arm - ANSWER: C. Pain relieved by food intake
Rationale:
