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
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
