The nurse is monitoring a client admitted to the hospital with a A. Notify the health care provider (HCP).
diagnosis of appendicitis who is scheduled for surgery in 2 hours.
The client begins to complain of increased abdominal pain and Rationale:
begins to vomit. On assessment, the nurse notes that the abdomen On the basis of the signs and symptoms presented in the question, the nurse should suspect
is distended and bowel sounds are diminished. Which is the most peritonitis and notify the HCP. Administering pain medication is not an appropriate
appropriate nursing intervention? 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
A. Notify the health care provider (HCP). of nursing practice, although the HCP probably would perform the surgery earlier than the
B. Administer the prescribed pain medication. prescheduled time.
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 client has just had a hemorrhoidectomy. Which nursing A. Administer stool softeners as prescribed.
interventions are appropriate for this client? Select all that apply. 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.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary Rationale:
retention. Nursing interventions after a hemorrhoidectomy are aimed at management of pain and
C. Encourage a high-fiber diet to promote bowel movements avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the
without straining. client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack
D. Apply cold packs to the anal-rectal area over the dressing until will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
the packing is removed.
E. Help the client to a Fowler's position to place pressure on the
rectal area and decrease bleeding.
,The nurse is planning to teach a client with gastroesophageal A. Coffee
reflux disease (GERD) about substances to avoid. Which items B. Chocolate
should the nurse include on this list? Select all that apply. C. Peppermint
E. Fried chicken
A. Coffee
B. Chocolate Rationale:
C. Peppermint Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus
D. Nonfat milk will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
E. Fried chicken Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods,
F. Scrambled eggs carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.
A client has undergone esophagogastroduodenoscopy. The nurse 4. Assessing for the return of the gag reflex
should place highest priority on which item as part of the client's
care plan? Rationale:
The nurse places highest priority on assessing for return of the gag reflex. This assessment
1. Monitoring the temperature addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden
2. Monitoring complaints of heartburn increase in temperature, which could indicate perforation of the gastrointestinal tract. This
3. Giving warm gargles for a sore throat complication would be accompanied by other signs as well, such as pain. Monitoring for sore
4. Assessing for the return of the gag reflex 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 A. Nuts
diagnosis of chronic gastritis. The nurse instructs the client to C. Liver
include which foods rich in vitamin B12 in the diet? Select all E. Lentils
that apply.
Rationale:
A. Nuts Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the
B. Corn loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an
C. Liver inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must
D. Apples increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin,
E. Lentils such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.
F. Bananas
,The nurse is monitoring a client with a diagnosis of peptic ulcer. D. A rigid, boardlike abdomen
Which assessment finding would most likely indicate perforation
of the ulcer? Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp,
A. Bradycardia intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen,
B. Numbness in the legs which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur
C. Nausea and vomiting as hypovolemic shock develops. Numbness in the legs is not an associated finding.
D. A rigid, boardlike abdomen
The nurse is caring for a client following a gastrojejunostomy C. Irrigating the nasogastric tube
(Billroth II procedure). Which postoperative prescription should
the nurse question and verify? Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
A. Leg exercises anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for
B. Early ambulation preventing the retention of gastric secretions. The nurse should never irrigate or reposition
C. Irrigating the nasogastric tube the gastric tube after gastric surgery, unless specifically prescribed by the health care
D. Coughing and deep-breathing exercises 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 C. Limit the fluids taken with meals.
gastrectomy and should instruct the client to take which measure
to assist in preventing dumping syndrome? Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that
A. Ambulate following a meal. occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early
B. Eat high-carbohydrate foods. manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia,
C. Limit the fluids taken with meals. syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct
D. Sit in a high Fowler's position during meals. 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 A. "I should increase the fiber in my diet."
diagnosed Crohn's disease about dietary measures to implement
during exacerbation episodes. Which statement made by the Rationale:
client indicates a need for further instruction? 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
A. "I should increase the fiber in my diet." narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and
B. "I will need to avoid caffeinated beverages." remissions. If stress increases the symptoms of the disease, the client is taught stress
C. "I'm going to learn some stress reduction techniques." management techniques and may require additional counseling. The client is taught to avoid
D. "I can have exacerbations and remissions with Crohn's gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein
disease." 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 C. Pain relieved by food intake
history of duodenal ulcer. To determine whether the problem is
currently active, the nurse should assess the client for which Rationale:
sign(s)/symptom(s) of duodenal ulcer? A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients
generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in
A. Weight loss the mid-epigastric area. The client with duodenal ulcer usually does not experience weight
B. Nausea and vomiting loss or nausea and vomiting. These symptoms are more typical in the client with a gastric
C. Pain relieved by food intake ulcer.
D. Pain radiating down the right arm
A client with hiatal hernia chronically experiences heartburn A. Lying recumbent following meals
following meals. The nurse should plan to teach the client to
avoid which action because it is contraindicated with a hiatal Rationale:
hernia? Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm
where the esophagus usually is positioned. The client usually experiences pain from reflux
A. Lying recumbent following meals caused by ingestion of irritating foods, lying flat following meals or at night, and eating large
B. Consuming small, frequent, bland meals or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of
C. Taking H2-receptor antagonist medication H2-receptor antagonists and antacids; and elevation of the thorax following meals and during
D. Raising the head of the bed on 6-inch (15 cm) blocks sleep.
diagnosis of appendicitis who is scheduled for surgery in 2 hours.
The client begins to complain of increased abdominal pain and Rationale:
begins to vomit. On assessment, the nurse notes that the abdomen On the basis of the signs and symptoms presented in the question, the nurse should suspect
is distended and bowel sounds are diminished. Which is the most peritonitis and notify the HCP. Administering pain medication is not an appropriate
appropriate nursing intervention? 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
A. Notify the health care provider (HCP). of nursing practice, although the HCP probably would perform the surgery earlier than the
B. Administer the prescribed pain medication. prescheduled time.
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 client has just had a hemorrhoidectomy. Which nursing A. Administer stool softeners as prescribed.
interventions are appropriate for this client? Select all that apply. 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.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary Rationale:
retention. Nursing interventions after a hemorrhoidectomy are aimed at management of pain and
C. Encourage a high-fiber diet to promote bowel movements avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the
without straining. client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack
D. Apply cold packs to the anal-rectal area over the dressing until will increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
the packing is removed.
E. Help the client to a Fowler's position to place pressure on the
rectal area and decrease bleeding.
,The nurse is planning to teach a client with gastroesophageal A. Coffee
reflux disease (GERD) about substances to avoid. Which items B. Chocolate
should the nurse include on this list? Select all that apply. C. Peppermint
E. Fried chicken
A. Coffee
B. Chocolate Rationale:
C. Peppermint Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus
D. Nonfat milk will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
E. Fried chicken Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods,
F. Scrambled eggs carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.
A client has undergone esophagogastroduodenoscopy. The nurse 4. Assessing for the return of the gag reflex
should place highest priority on which item as part of the client's
care plan? Rationale:
The nurse places highest priority on assessing for return of the gag reflex. This assessment
1. Monitoring the temperature addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden
2. Monitoring complaints of heartburn increase in temperature, which could indicate perforation of the gastrointestinal tract. This
3. Giving warm gargles for a sore throat complication would be accompanied by other signs as well, such as pain. Monitoring for sore
4. Assessing for the return of the gag reflex 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 A. Nuts
diagnosis of chronic gastritis. The nurse instructs the client to C. Liver
include which foods rich in vitamin B12 in the diet? Select all E. Lentils
that apply.
Rationale:
A. Nuts Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the
B. Corn loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an
C. Liver inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must
D. Apples increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin,
E. Lentils such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.
F. Bananas
,The nurse is monitoring a client with a diagnosis of peptic ulcer. D. A rigid, boardlike abdomen
Which assessment finding would most likely indicate perforation
of the ulcer? Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp,
A. Bradycardia intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen,
B. Numbness in the legs which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur
C. Nausea and vomiting as hypovolemic shock develops. Numbness in the legs is not an associated finding.
D. A rigid, boardlike abdomen
The nurse is caring for a client following a gastrojejunostomy C. Irrigating the nasogastric tube
(Billroth II procedure). Which postoperative prescription should
the nurse question and verify? Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
A. Leg exercises anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for
B. Early ambulation preventing the retention of gastric secretions. The nurse should never irrigate or reposition
C. Irrigating the nasogastric tube the gastric tube after gastric surgery, unless specifically prescribed by the health care
D. Coughing and deep-breathing exercises 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 C. Limit the fluids taken with meals.
gastrectomy and should instruct the client to take which measure
to assist in preventing dumping syndrome? Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that
A. Ambulate following a meal. occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early
B. Eat high-carbohydrate foods. manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia,
C. Limit the fluids taken with meals. syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct
D. Sit in a high Fowler's position during meals. 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 A. "I should increase the fiber in my diet."
diagnosed Crohn's disease about dietary measures to implement
during exacerbation episodes. Which statement made by the Rationale:
client indicates a need for further instruction? 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
A. "I should increase the fiber in my diet." narrowed lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and
B. "I will need to avoid caffeinated beverages." remissions. If stress increases the symptoms of the disease, the client is taught stress
C. "I'm going to learn some stress reduction techniques." management techniques and may require additional counseling. The client is taught to avoid
D. "I can have exacerbations and remissions with Crohn's gastrointestinal stimulants containing caffeine and to follow a high-calorie and high-protein
disease." 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 C. Pain relieved by food intake
history of duodenal ulcer. To determine whether the problem is
currently active, the nurse should assess the client for which Rationale:
sign(s)/symptom(s) of duodenal ulcer? A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients
generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in
A. Weight loss the mid-epigastric area. The client with duodenal ulcer usually does not experience weight
B. Nausea and vomiting loss or nausea and vomiting. These symptoms are more typical in the client with a gastric
C. Pain relieved by food intake ulcer.
D. Pain radiating down the right arm
A client with hiatal hernia chronically experiences heartburn A. Lying recumbent following meals
following meals. The nurse should plan to teach the client to
avoid which action because it is contraindicated with a hiatal Rationale:
hernia? Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm
where the esophagus usually is positioned. The client usually experiences pain from reflux
A. Lying recumbent following meals caused by ingestion of irritating foods, lying flat following meals or at night, and eating large
B. Consuming small, frequent, bland meals or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of
C. Taking H2-receptor antagonist medication H2-receptor antagonists and antacids; and elevation of the thorax following meals and during
D. Raising the head of the bed on 6-inch (15 cm) blocks sleep.
