Med Surg Gastrointestinal NCLEX Questions|
RECENT UPDATE|COMPREHENSIVE
QUESTIONS AND VERIFIED SOLUTIONS |GET IT
100% ACCURATE!!
Save
Terms in this set (86)
The nurse is monitoring a client A. Notify the health care provider (HCP).
admitted to the hospital with a
diagnosis of appendicitis who is Rationale:
scheduled for surgery in 2 hours. On the basis of the signs and symptoms
The client begins to complain of presented in the question, the nurse should
increased abdominal pain and suspect peritonitis and notify the HCP.
begins to vomit. On assessment, the Administering pain medication is not an
nurse notes that the abdomen is appropriate intervention. Heat should never be
distended and bowel sounds are applied to the abdomen of a client with
diminished. Which is the most suspected appendicitis because of the risk of
appropriate nursing intervention? rupture. Scheduling surgical time is not within the
scope of nursing practice, although the HCP
A. Notify the health care provider probably would perform the surgery earlier than
(HCP). the prescheduled time.
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 client has just had a A. Administer stool softeners as prescribed.
hemorrhoidectomy. Which nursing C. Encourage a high-fiber diet to promote bowel
interventions are appropriate for movements without straining.
this client? Select all that apply. D. Apply cold packs to the anal-rectal area over
the dressing until the packing is removed.
A. Administer stool softeners as
prescribed. Rationale:
B. Instruct the client to limit fluid Nursing interventions after a hemorrhoidectomy
intake to avoid urinary retention. are aimed at management of pain and avoidance
C. Encourage a high-fiber diet to of bleeding and incision rupture. Stool softeners
promote bowel movements without and a high-fiber diet will help the client to avoid
straining. straining, thereby reducing the chances of
D. Apply cold packs to the anal- rupturing the incision. An ice pack will increase
rectal area over the dressing until comfort and decrease bleeding. Options 2 and 5
the packing is removed. are incorrect interventions.
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 A. Coffee
client with gastroesophageal reflux B. Chocolate
disease (GERD) about substances C. Peppermint
to avoid. Which items should the E. Fried chicken
nurse include on this list? Select all
that apply. Rationale:
Foods that decrease lower esophageal sphincter
A. Coffee (LES) pressure and irritate the esophagus will
B. Chocolate increase reflux and exacerbate the symptoms of
C. Peppermint GERD and therefore should be avoided.
D. Nonfat milk Aggravating substances include coffee,
E. Fried chicken 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 4. Assessing for the return of the gag reflex
esophagogastroduodenoscopy.
The nurse should place highest Rationale:
priority on which item as part of the The nurse places highest priority on assessing for
client's care plan? return of the gag reflex. This assessment
addresses the client's airway. The nurse also
1. Monitoring the temperature monitors the client's vital signs and for a sudden
2. Monitoring complaints of increase in temperature, which could indicate
heartburn perforation of the gastrointestinal tract. This
3. Giving warm gargles for a sore complication would be accompanied by other
throat signs as well, such as pain. Monitoring for sore
4. Assessing for the return of the throat and heartburn are also important;
gag reflex however, the client's airway is the priority.
The nurse is providing dietary A. Nuts
teaching for a client with a C. Liver
diagnosis of chronic gastritis. The E. Lentils
nurse instructs the client to include
which foods rich in vitamin B12 in Rationale:
the diet? Select all that apply. Chronic gastritis causes deterioration and
atrophy of the lining of the stomach, leading to
A. Nuts the loss of function of the parietal cells. The
B. Corn source of intrinsic factor is lost, which results in
C. Liver an inability to absorb vitamin B12, leading to
D. Apples development of pernicious anemia. Clients must
E. Lentils increase their intake of vitamin B12 by increasing
F. Bananas 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 D. A rigid, boardlike abdomen
a diagnosis of peptic ulcer. Which
assessment finding would most Rationale:
likely indicate perforation of the Perforation of an ulcer is a surgical emergency
ulcer? and is characterized by sudden, sharp,
intolerable severe pain beginning in the mid-
A. Bradycardia epigastric area and spreading over the abdomen,
B. Numbness in the legs which becomes rigid and boardlike. Nausea and
C. Nausea and vomiting vomiting may occur. Tachycardia may occur as
D. A rigid, boardlike abdomen hypovolemic shock develops. Numbness in the
legs is not an associated finding.
The nurse is caring for a client C. Irrigating the nasogastric tube
following a gastrojejunostomy
(Billroth II procedure). Which Rationale:
postoperative prescription should In a gastrojejunostomy (Billroth II procedure), the
the nurse question and verify? proximal remnant of the stomach is anastomosed
to the proximal jejunum. Patency of the
A. Leg exercises nasogastric tube is critical for preventing the
B. Early ambulation retention of gastric secretions. The nurse should
C. Irrigating the nasogastric tube never irrigate or reposition the gastric tube after
D. Coughing and deep-breathing gastric surgery, unless specifically prescribed by
exercises the health care provider. In this situation, the
nurse should clarify the prescription. Options 1, 2,
and 4 are appropriate postoperative
interventions.
RECENT UPDATE|COMPREHENSIVE
QUESTIONS AND VERIFIED SOLUTIONS |GET IT
100% ACCURATE!!
Save
Terms in this set (86)
The nurse is monitoring a client A. Notify the health care provider (HCP).
admitted to the hospital with a
diagnosis of appendicitis who is Rationale:
scheduled for surgery in 2 hours. On the basis of the signs and symptoms
The client begins to complain of presented in the question, the nurse should
increased abdominal pain and suspect peritonitis and notify the HCP.
begins to vomit. On assessment, the Administering pain medication is not an
nurse notes that the abdomen is appropriate intervention. Heat should never be
distended and bowel sounds are applied to the abdomen of a client with
diminished. Which is the most suspected appendicitis because of the risk of
appropriate nursing intervention? rupture. Scheduling surgical time is not within the
scope of nursing practice, although the HCP
A. Notify the health care provider probably would perform the surgery earlier than
(HCP). the prescheduled time.
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 client has just had a A. Administer stool softeners as prescribed.
hemorrhoidectomy. Which nursing C. Encourage a high-fiber diet to promote bowel
interventions are appropriate for movements without straining.
this client? Select all that apply. D. Apply cold packs to the anal-rectal area over
the dressing until the packing is removed.
A. Administer stool softeners as
prescribed. Rationale:
B. Instruct the client to limit fluid Nursing interventions after a hemorrhoidectomy
intake to avoid urinary retention. are aimed at management of pain and avoidance
C. Encourage a high-fiber diet to of bleeding and incision rupture. Stool softeners
promote bowel movements without and a high-fiber diet will help the client to avoid
straining. straining, thereby reducing the chances of
D. Apply cold packs to the anal- rupturing the incision. An ice pack will increase
rectal area over the dressing until comfort and decrease bleeding. Options 2 and 5
the packing is removed. are incorrect interventions.
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 A. Coffee
client with gastroesophageal reflux B. Chocolate
disease (GERD) about substances C. Peppermint
to avoid. Which items should the E. Fried chicken
nurse include on this list? Select all
that apply. Rationale:
Foods that decrease lower esophageal sphincter
A. Coffee (LES) pressure and irritate the esophagus will
B. Chocolate increase reflux and exacerbate the symptoms of
C. Peppermint GERD and therefore should be avoided.
D. Nonfat milk Aggravating substances include coffee,
E. Fried chicken 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 4. Assessing for the return of the gag reflex
esophagogastroduodenoscopy.
The nurse should place highest Rationale:
priority on which item as part of the The nurse places highest priority on assessing for
client's care plan? return of the gag reflex. This assessment
addresses the client's airway. The nurse also
1. Monitoring the temperature monitors the client's vital signs and for a sudden
2. Monitoring complaints of increase in temperature, which could indicate
heartburn perforation of the gastrointestinal tract. This
3. Giving warm gargles for a sore complication would be accompanied by other
throat signs as well, such as pain. Monitoring for sore
4. Assessing for the return of the throat and heartburn are also important;
gag reflex however, the client's airway is the priority.
The nurse is providing dietary A. Nuts
teaching for a client with a C. Liver
diagnosis of chronic gastritis. The E. Lentils
nurse instructs the client to include
which foods rich in vitamin B12 in Rationale:
the diet? Select all that apply. Chronic gastritis causes deterioration and
atrophy of the lining of the stomach, leading to
A. Nuts the loss of function of the parietal cells. The
B. Corn source of intrinsic factor is lost, which results in
C. Liver an inability to absorb vitamin B12, leading to
D. Apples development of pernicious anemia. Clients must
E. Lentils increase their intake of vitamin B12 by increasing
F. Bananas 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 D. A rigid, boardlike abdomen
a diagnosis of peptic ulcer. Which
assessment finding would most Rationale:
likely indicate perforation of the Perforation of an ulcer is a surgical emergency
ulcer? and is characterized by sudden, sharp,
intolerable severe pain beginning in the mid-
A. Bradycardia epigastric area and spreading over the abdomen,
B. Numbness in the legs which becomes rigid and boardlike. Nausea and
C. Nausea and vomiting vomiting may occur. Tachycardia may occur as
D. A rigid, boardlike abdomen hypovolemic shock develops. Numbness in the
legs is not an associated finding.
The nurse is caring for a client C. Irrigating the nasogastric tube
following a gastrojejunostomy
(Billroth II procedure). Which Rationale:
postoperative prescription should In a gastrojejunostomy (Billroth II procedure), the
the nurse question and verify? proximal remnant of the stomach is anastomosed
to the proximal jejunum. Patency of the
A. Leg exercises nasogastric tube is critical for preventing the
B. Early ambulation retention of gastric secretions. The nurse should
C. Irrigating the nasogastric tube never irrigate or reposition the gastric tube after
D. Coughing and deep-breathing gastric surgery, unless specifically prescribed by
exercises the health care provider. In this situation, the
nurse should clarify the prescription. Options 1, 2,
and 4 are appropriate postoperative
interventions.
