Med Surg Gastrointestinal NCLEX Questions with 100% Verified
Answers Graded A+
The nurse is monitoring a client admitted to the pressure on the rectal area and decrease
hospital with a diagnosis of appendicitis who is bleeding. - ANSWERS - A. Administer stool
scheduled for surgery in 2 hours. The client softeners as prescribed.
begins to complain of increased abdominal pain C. Encourage a high-fiber diet to promote bowel
and begins to vomit. On assessment, the nurse movements without straining.
notes that the abdomen is distended and bowel D. Apply cold packs to the anal-rectal area over
sounds are diminished. Which is the most the dressing until the packing is removed.
appropriate nursing intervention?
Rationale:
A. Notify the health care provider (HCP). Nursing interventions after a hemorrhoidectomy
B. Administer the prescribed pain medication. are aimed at management of pain and avoidance
C. Call and ask the operating room team to of bleeding and incision rupture. Stool softeners
perform surgery as soon as possible. and a high-fiber diet will help the client to avoid
D. Reposition the client and apply a heating pad straining, thereby reducing the chances of
on the warm setting to the client's abdomen. - rupturing the incision. An ice pack will increase
ANSWERS - A. Notify the health care comfort and decrease bleeding. Options 2 and 5
provider (HCP). are incorrect interventions.
Rationale:
On the basis of the signs and symptoms
presented in the question, the nurse should The nurse is planning to teach a client with
suspect peritonitis and notify the HCP. gastroesophageal reflux disease (GERD) about
Administering pain medication is not an substances to avoid. Which items should the
appropriate intervention. Heat should never be nurse include on this list? Select all that apply.
applied to the abdomen of a client with
suspected appendicitis because of the risk of A. Coffee
rupture. Scheduling surgical time is not within the B. Chocolate
scope of nursing practice, although the HCP C. Peppermint
probably would perform the surgery earlier than D. Nonfat milk
the prescheduled time. E. Fried chicken
F. Scrambled eggs - ANSWERS - A. Coffee
B. Chocolate
C. Peppermint
A client has just had a hemorrhoidectomy. Which E. Fried chicken
nursing interventions are appropriate for this
client? Select all that apply. Rationale:
Foods that decrease lower esophageal sphincter
A. Administer stool softeners as prescribed. (LES) pressure and irritate the esophagus will
B. Instruct the client to limit fluid intake to avoid increase reflux and exacerbate the symptoms of
urinary retention. GERD and therefore should be avoided.
C. Encourage a high-fiber diet to promote bowel Aggravating substances include coffee,
movements without straining. chocolate, peppermint, fried or fatty foods,
D. Apply cold packs to the anal-rectal area over carbonated beverages, and alcohol. Options 4
the dressing until the packing is removed. and 6 do not promote this effect.
E. Help the client to a Fowler's position to place
,Med Surg Gastrointestinal NCLEX Questions with 100% Verified
Answers Graded A+
atrophy of the lining of the stomach, leading to
the loss of function of the parietal cells. The
A client has undergone source of intrinsic factor is lost, which results in
esophagogastroduodenoscopy. The nurse an inability to absorb vitamin B12, leading to
should place highest priority on which item as development of pernicious anemia. Clients must
part of the client's care plan? increase their intake of vitamin B12 by increasing
consumption of foods rich in this vitamin, such as
1. Monitoring the temperature nuts, organ meats, dried beans, citrus fruits,
2. Monitoring complaints of heartburn green leafy vegetables, and yeast.
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex -
ANSWERS - 4. Assessing for the return of
the gag reflex The nurse is monitoring a client with a diagnosis
of peptic ulcer. Which assessment finding would
Rationale: most likely indicate perforation of the ulcer?
The nurse places highest priority on assessing
for return of the gag reflex. This assessment A. Bradycardia
addresses the client's airway. The nurse also B. Numbness in the legs
monitors the client's vital signs and for a sudden C. Nausea and vomiting
increase in temperature, which could indicate D. A rigid, boardlike abdomen -
perforation of the gastrointestinal tract. This ANSWERS - D. A rigid, boardlike abdomen
complication would be accompanied by other
signs as well, such as pain. Monitoring for sore Rationale:
throat and heartburn are also important; Perforation of an ulcer is a surgical emergency
however, the client's airway is the priority. 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
The nurse is providing dietary teaching for a vomiting may occur. Tachycardia may occur as
client with a diagnosis of chronic gastritis. The hypovolemic shock develops. Numbness in the
nurse instructs the client to include which foods legs is not an associated finding.
rich in vitamin B12 in the diet? Select all that
apply.
A. Nuts The nurse is caring for a client following a
B. Corn gastrojejunostomy (Billroth II procedure). Which
C. Liver postoperative prescription should the nurse
D. Apples question and verify?
E. Lentils
F. Bananas - ANSWERS - A. Nuts A. Leg exercises
C. Liver B. Early ambulation
E. Lentils C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises -
Rationale: ANSWERS - C. Irrigating the nasogastric
Chronic gastritis causes deterioration and tube
, Med Surg Gastrointestinal NCLEX Questions with 100% Verified
Answers Graded A+
Rationale: The nurse is providing discharge teaching for a
In a gastrojejunostomy (Billroth II procedure), the client with newly diagnosed Crohn's disease
proximal remnant of the stomach is anastomosed about dietary measures to implement during
to the proximal jejunum. Patency of the exacerbation episodes. Which statement made
nasogastric tube is critical for preventing the by the client indicates a need for further
retention of gastric secretions. The nurse should instruction?
never irrigate or reposition the gastric tube after
gastric surgery, unless specifically prescribed by A. "I should increase the fiber in my diet."
the health care provider. In this situation, the B. "I will need to avoid caffeinated beverages."
nurse should clarify the prescription. Options 1, C. "I'm going to learn some stress reduction
2, and 4 are appropriate postoperative techniques."
interventions. D. "I can have exacerbations and remissions with
Crohn's disease." - ANSWERS - A. "I
should increase the fiber in my diet."
The nurse is providing discharge instructions to a Rationale:
client following gastrectomy and should instruct Crohn's disease is an inflammatory disease that
the client to take which measure to assist in can occur anywhere in the gastrointestinal tract
preventing dumping syndrome? but most often affects the terminal ileum and
leads to thickening and scarring, a narrowed
A. Ambulate following a meal. lumen, fistulas, ulcerations, and abscesses. It is
B. Eat high-carbohydrate foods. characterized by exacerbations and remissions. If
C. Limit the fluids taken with meals. stress increases the symptoms of the disease,
D. Sit in a high Fowler's position during meals. - the client is taught stress management
ANSWERS - C. Limit the fluids taken with techniques and may require additional
meals. counseling. The client is taught to avoid
gastrointestinal stimulants containing caffeine
Rationale: and to follow a high-calorie and high-protein diet.
Dumping syndrome is a term that refers to a A low-fiber diet may be prescribed, especially
constellation of vasomotor symptoms that occurs during periods of exacerbation.
after eating, especially following a
gastrojejunostomy (Billroth II procedure). Early
manifestations usually occur within 30 minutes of
eating and include vertigo, tachycardia, syncope, The nurse is doing an admission assessment on
sweating, pallor, palpitations, and the desire to a client with a history of duodenal ulcer. To
lie down. The nurse should instruct the client to determine whether the problem is currently
decrease the amount of fluid taken at meals and active, the nurse should assess the client for
to avoid high-carbohydrate foods, including fluids which sign(s)/symptom(s) of duodenal ulcer?
such as fruit nectars; to assume a low Fowler's
position during meals; to lie down for 30 minutes A. Weight loss
after eating to delay gastric emptying; and to B. Nausea and vomiting
take antispasmodics as prescribed. C. Pain relieved by food intake
D. Pain radiating down the right arm -
ANSWERS - C. Pain relieved by food intake
Answers Graded A+
The nurse is monitoring a client admitted to the pressure on the rectal area and decrease
hospital with a diagnosis of appendicitis who is bleeding. - ANSWERS - A. Administer stool
scheduled for surgery in 2 hours. The client softeners as prescribed.
begins to complain of increased abdominal pain C. Encourage a high-fiber diet to promote bowel
and begins to vomit. On assessment, the nurse movements without straining.
notes that the abdomen is distended and bowel D. Apply cold packs to the anal-rectal area over
sounds are diminished. Which is the most the dressing until the packing is removed.
appropriate nursing intervention?
Rationale:
A. Notify the health care provider (HCP). Nursing interventions after a hemorrhoidectomy
B. Administer the prescribed pain medication. are aimed at management of pain and avoidance
C. Call and ask the operating room team to of bleeding and incision rupture. Stool softeners
perform surgery as soon as possible. and a high-fiber diet will help the client to avoid
D. Reposition the client and apply a heating pad straining, thereby reducing the chances of
on the warm setting to the client's abdomen. - rupturing the incision. An ice pack will increase
ANSWERS - A. Notify the health care comfort and decrease bleeding. Options 2 and 5
provider (HCP). are incorrect interventions.
Rationale:
On the basis of the signs and symptoms
presented in the question, the nurse should The nurse is planning to teach a client with
suspect peritonitis and notify the HCP. gastroesophageal reflux disease (GERD) about
Administering pain medication is not an substances to avoid. Which items should the
appropriate intervention. Heat should never be nurse include on this list? Select all that apply.
applied to the abdomen of a client with
suspected appendicitis because of the risk of A. Coffee
rupture. Scheduling surgical time is not within the B. Chocolate
scope of nursing practice, although the HCP C. Peppermint
probably would perform the surgery earlier than D. Nonfat milk
the prescheduled time. E. Fried chicken
F. Scrambled eggs - ANSWERS - A. Coffee
B. Chocolate
C. Peppermint
A client has just had a hemorrhoidectomy. Which E. Fried chicken
nursing interventions are appropriate for this
client? Select all that apply. Rationale:
Foods that decrease lower esophageal sphincter
A. Administer stool softeners as prescribed. (LES) pressure and irritate the esophagus will
B. Instruct the client to limit fluid intake to avoid increase reflux and exacerbate the symptoms of
urinary retention. GERD and therefore should be avoided.
C. Encourage a high-fiber diet to promote bowel Aggravating substances include coffee,
movements without straining. chocolate, peppermint, fried or fatty foods,
D. Apply cold packs to the anal-rectal area over carbonated beverages, and alcohol. Options 4
the dressing until the packing is removed. and 6 do not promote this effect.
E. Help the client to a Fowler's position to place
,Med Surg Gastrointestinal NCLEX Questions with 100% Verified
Answers Graded A+
atrophy of the lining of the stomach, leading to
the loss of function of the parietal cells. The
A client has undergone source of intrinsic factor is lost, which results in
esophagogastroduodenoscopy. The nurse an inability to absorb vitamin B12, leading to
should place highest priority on which item as development of pernicious anemia. Clients must
part of the client's care plan? increase their intake of vitamin B12 by increasing
consumption of foods rich in this vitamin, such as
1. Monitoring the temperature nuts, organ meats, dried beans, citrus fruits,
2. Monitoring complaints of heartburn green leafy vegetables, and yeast.
3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex -
ANSWERS - 4. Assessing for the return of
the gag reflex The nurse is monitoring a client with a diagnosis
of peptic ulcer. Which assessment finding would
Rationale: most likely indicate perforation of the ulcer?
The nurse places highest priority on assessing
for return of the gag reflex. This assessment A. Bradycardia
addresses the client's airway. The nurse also B. Numbness in the legs
monitors the client's vital signs and for a sudden C. Nausea and vomiting
increase in temperature, which could indicate D. A rigid, boardlike abdomen -
perforation of the gastrointestinal tract. This ANSWERS - D. A rigid, boardlike abdomen
complication would be accompanied by other
signs as well, such as pain. Monitoring for sore Rationale:
throat and heartburn are also important; Perforation of an ulcer is a surgical emergency
however, the client's airway is the priority. 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
The nurse is providing dietary teaching for a vomiting may occur. Tachycardia may occur as
client with a diagnosis of chronic gastritis. The hypovolemic shock develops. Numbness in the
nurse instructs the client to include which foods legs is not an associated finding.
rich in vitamin B12 in the diet? Select all that
apply.
A. Nuts The nurse is caring for a client following a
B. Corn gastrojejunostomy (Billroth II procedure). Which
C. Liver postoperative prescription should the nurse
D. Apples question and verify?
E. Lentils
F. Bananas - ANSWERS - A. Nuts A. Leg exercises
C. Liver B. Early ambulation
E. Lentils C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises -
Rationale: ANSWERS - C. Irrigating the nasogastric
Chronic gastritis causes deterioration and tube
, Med Surg Gastrointestinal NCLEX Questions with 100% Verified
Answers Graded A+
Rationale: The nurse is providing discharge teaching for a
In a gastrojejunostomy (Billroth II procedure), the client with newly diagnosed Crohn's disease
proximal remnant of the stomach is anastomosed about dietary measures to implement during
to the proximal jejunum. Patency of the exacerbation episodes. Which statement made
nasogastric tube is critical for preventing the by the client indicates a need for further
retention of gastric secretions. The nurse should instruction?
never irrigate or reposition the gastric tube after
gastric surgery, unless specifically prescribed by A. "I should increase the fiber in my diet."
the health care provider. In this situation, the B. "I will need to avoid caffeinated beverages."
nurse should clarify the prescription. Options 1, C. "I'm going to learn some stress reduction
2, and 4 are appropriate postoperative techniques."
interventions. D. "I can have exacerbations and remissions with
Crohn's disease." - ANSWERS - A. "I
should increase the fiber in my diet."
The nurse is providing discharge instructions to a Rationale:
client following gastrectomy and should instruct Crohn's disease is an inflammatory disease that
the client to take which measure to assist in can occur anywhere in the gastrointestinal tract
preventing dumping syndrome? but most often affects the terminal ileum and
leads to thickening and scarring, a narrowed
A. Ambulate following a meal. lumen, fistulas, ulcerations, and abscesses. It is
B. Eat high-carbohydrate foods. characterized by exacerbations and remissions. If
C. Limit the fluids taken with meals. stress increases the symptoms of the disease,
D. Sit in a high Fowler's position during meals. - the client is taught stress management
ANSWERS - C. Limit the fluids taken with techniques and may require additional
meals. counseling. The client is taught to avoid
gastrointestinal stimulants containing caffeine
Rationale: and to follow a high-calorie and high-protein diet.
Dumping syndrome is a term that refers to a A low-fiber diet may be prescribed, especially
constellation of vasomotor symptoms that occurs during periods of exacerbation.
after eating, especially following a
gastrojejunostomy (Billroth II procedure). Early
manifestations usually occur within 30 minutes of
eating and include vertigo, tachycardia, syncope, The nurse is doing an admission assessment on
sweating, pallor, palpitations, and the desire to a client with a history of duodenal ulcer. To
lie down. The nurse should instruct the client to determine whether the problem is currently
decrease the amount of fluid taken at meals and active, the nurse should assess the client for
to avoid high-carbohydrate foods, including fluids which sign(s)/symptom(s) of duodenal ulcer?
such as fruit nectars; to assume a low Fowler's
position during meals; to lie down for 30 minutes A. Weight loss
after eating to delay gastric emptying; and to B. Nausea and vomiting
take antispasmodics as prescribed. C. Pain relieved by food intake
D. Pain radiating down the right arm -
ANSWERS - C. Pain relieved by food intake
