Med Surg Gastrointestinal NCLEX Questions/
Strategies Review of Key Quizzes & Correct
Answers.
The nurse is monitoring a client admitted to the A. Notify the health care provider (HCP).
hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client Rationale:
begins to complain of increased abdominal pain On the basis of the signs and symptoms
and begins to vomit. On assessment, the nurse presented in the question, the nurse
notes that the abdomen is distended and bowel should suspect peritonitis and notify
sounds are diminished. Which is the most the HCP. Administering pain medication
appropriate nursing intervention? is not an appropriate intervention. Heat
should never be applied to the
A. Notify the health careprovider (HCP). abdomen of a client with suspected
B. Administer theprescribed pain appendicitis because of the risk of
medication. rupture.
C. Call and ask theoperating room team to Scheduling surgical time is not within the
perform surgery as soon as possible. scope of nursing practice, although the
HCP probably would perform the surgery
D. Reposition the clientand apply a heating
earlier than the prescheduled time.
pad on the warm setting to the client's abdomen.
Terms in this set (86)
,A client has just had a A. Administer stool softeners as prescribed.
hemorrhoidectomy. Which C. Encourage a high-fiber diet to promote bowelmovements
nursing interventions are without straining.
appropriate for this client? D. Apply cold packs to the anal-rectal area over thedressing until
Select all that apply. the packing is removed.
A. Administer stool Rationale:
softeners as prescribed. B. Nursing interventions after a hemorrhoidectomy are aimed
Instruct the client to limit at management of pain and avoidance of bleeding and
incision rupture. Stool softeners and a high-fiber diet will
fluid intake to avoid
help the client to avoid straining, thereby reducing the
urinary retention. chances of rupturing the incision. An ice pack will increase
C. Encourage a high- comfort and decrease bleeding. Options 2 and 5 are
fiberdiet to promote bowel incorrect interventions.
movements without
straining.
D. Apply cold packs to
theanal-rectal area over the
dressing until the packing is
removed.
E. Help the client to
aFowler's position to place
pressure on the rectal area
and decrease bleeding.
,The nurse is planning to A. Coffee
teach a client with B. Chocolate
gastroesophageal reflux C. PeppermintE. Fried chicken
disease (GERD) about
substances to avoid. Which Rationale:
items should the nurse Foods that decrease lower esophageal sphincter (LES)
include on this list? pressure and irritate the esophagus will increase reflux and
exacerbate the symptoms of GERD and therefore should be
Select all that apply.
avoided. Aggravating substances include coffee, chocolate,
peppermint, fried or fatty foods, carbonated beverages, and
A. Coffee alcohol. Options 4 and 6 do not promote this effect.
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs
A client has undergone 4. Assessing for the return of the gag reflex
esophagogastroduodeno
scopy. The nurse should Rationale:
place highest priority on The nurse places highest priority on assessing for return of
the gag reflex. This assessment addresses the client's
which item as part of the
airway. The nurse also monitors the client's vital signs and
client's care plan? for a sudden increase in temperature, which could indicate
perforation of the gastrointestinal tract. This complication
1. Monitoring would be accompanied by other signs as well, such as pain.
Monitoring for sore throat and heartburn are also
thetemperature
important; however, the client's airway is the priority.
2. Monitoring
complaintsof heartburn
3. Giving warm gargles
fora sore throat
4. Assessing for the
returnof the gag reflex
, The nurse is providing dietary A. Nuts
teaching for a client with a C. Liver
diagnosis of chronic gastritis. E. Lentils
The nurse instructs the client
to include which foods rich in Rationale:
vitamin B12 in the diet? Chronic gastritis causes deterioration and atrophy of the
Select all that apply. 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
A. Nuts development of pernicious anemia. Clients must increase
B. Corn their intake of vitamin B12 by increasing consumption of
C. Liver foods rich in this vitamin, such as nuts, organ meats, dried
beans, citrus fruits, green leafy vegetables, and yeast.
D. Apples
E. Lentils
F. Bananas
The nurse is monitoring a D. A rigid, boardlike abdomen
client with a diagnosis of
peptic ulcer. Which Rationale:
assessment finding would Perforation of an ulcer is a surgical emergency and is
characterized by sudden, sharp, intolerable severe pain
most likely indicate
beginning in the mid-epigastric area and spreading over the
perforation of the ulcer? abdomen, which becomes rigid and boardlike. Nausea and
vomiting may occur. Tachycardia may occur as hypovolemic
A. Bradycardia shock develops. Numbness in the legs is not an associated
B. Numbness in the legs finding.
C. Nausea and
vomitingD. A rigid, boardlike
abdomen
Strategies Review of Key Quizzes & Correct
Answers.
The nurse is monitoring a client admitted to the A. Notify the health care provider (HCP).
hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client Rationale:
begins to complain of increased abdominal pain On the basis of the signs and symptoms
and begins to vomit. On assessment, the nurse presented in the question, the nurse
notes that the abdomen is distended and bowel should suspect peritonitis and notify
sounds are diminished. Which is the most the HCP. Administering pain medication
appropriate nursing intervention? is not an appropriate intervention. Heat
should never be applied to the
A. Notify the health careprovider (HCP). abdomen of a client with suspected
B. Administer theprescribed pain appendicitis because of the risk of
medication. rupture.
C. Call and ask theoperating room team to Scheduling surgical time is not within the
perform surgery as soon as possible. scope of nursing practice, although the
HCP probably would perform the surgery
D. Reposition the clientand apply a heating
earlier than the prescheduled time.
pad on the warm setting to the client's abdomen.
Terms in this set (86)
,A client has just had a A. Administer stool softeners as prescribed.
hemorrhoidectomy. Which C. Encourage a high-fiber diet to promote bowelmovements
nursing interventions are without straining.
appropriate for this client? D. Apply cold packs to the anal-rectal area over thedressing until
Select all that apply. the packing is removed.
A. Administer stool Rationale:
softeners as prescribed. B. Nursing interventions after a hemorrhoidectomy are aimed
Instruct the client to limit at management of pain and avoidance of bleeding and
incision rupture. Stool softeners and a high-fiber diet will
fluid intake to avoid
help the client to avoid straining, thereby reducing the
urinary retention. chances of rupturing the incision. An ice pack will increase
C. Encourage a high- comfort and decrease bleeding. Options 2 and 5 are
fiberdiet to promote bowel incorrect interventions.
movements without
straining.
D. Apply cold packs to
theanal-rectal area over the
dressing until the packing is
removed.
E. Help the client to
aFowler's position to place
pressure on the rectal area
and decrease bleeding.
,The nurse is planning to A. Coffee
teach a client with B. Chocolate
gastroesophageal reflux C. PeppermintE. Fried chicken
disease (GERD) about
substances to avoid. Which Rationale:
items should the nurse Foods that decrease lower esophageal sphincter (LES)
include on this list? pressure and irritate the esophagus will increase reflux and
exacerbate the symptoms of GERD and therefore should be
Select all that apply.
avoided. Aggravating substances include coffee, chocolate,
peppermint, fried or fatty foods, carbonated beverages, and
A. Coffee alcohol. Options 4 and 6 do not promote this effect.
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs
A client has undergone 4. Assessing for the return of the gag reflex
esophagogastroduodeno
scopy. The nurse should Rationale:
place highest priority on The nurse places highest priority on assessing for return of
the gag reflex. This assessment addresses the client's
which item as part of the
airway. The nurse also monitors the client's vital signs and
client's care plan? for a sudden increase in temperature, which could indicate
perforation of the gastrointestinal tract. This complication
1. Monitoring would be accompanied by other signs as well, such as pain.
Monitoring for sore throat and heartburn are also
thetemperature
important; however, the client's airway is the priority.
2. Monitoring
complaintsof heartburn
3. Giving warm gargles
fora sore throat
4. Assessing for the
returnof the gag reflex
, The nurse is providing dietary A. Nuts
teaching for a client with a C. Liver
diagnosis of chronic gastritis. E. Lentils
The nurse instructs the client
to include which foods rich in Rationale:
vitamin B12 in the diet? Chronic gastritis causes deterioration and atrophy of the
Select all that apply. 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
A. Nuts development of pernicious anemia. Clients must increase
B. Corn their intake of vitamin B12 by increasing consumption of
C. Liver foods rich in this vitamin, such as nuts, organ meats, dried
beans, citrus fruits, green leafy vegetables, and yeast.
D. Apples
E. Lentils
F. Bananas
The nurse is monitoring a D. A rigid, boardlike abdomen
client with a diagnosis of
peptic ulcer. Which Rationale:
assessment finding would Perforation of an ulcer is a surgical emergency and is
characterized by sudden, sharp, intolerable severe pain
most likely indicate
beginning in the mid-epigastric area and spreading over the
perforation of the ulcer? abdomen, which becomes rigid and boardlike. Nausea and
vomiting may occur. Tachycardia may occur as hypovolemic
A. Bradycardia shock develops. Numbness in the legs is not an associated
B. Numbness in the legs finding.
C. Nausea and
vomitingD. A rigid, boardlike
abdomen
