ATI MED-SURG GASTROINTESTINAL LATEST
ACTUAL EXAM | 100% VERIFIED TEST BANK 2025
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. -
E. Answer-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. -
F. Answer-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 -
G. Answer-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 -
5. Answer-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 -
G. Answer-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 -
Answer-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 -
Answer-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. -
Answer-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 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 diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." -
Answer-A. "I should increase the fiber in my diet."
Rationale:
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 narrowed
lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If
stress increases the symptoms of the disease, the client is taught stress management techniques
and may require additional counseling. The client is taught to avoid gastrointestinal stimulants
containing caffeine and to follow a high-calorie and high-protein 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 history of duodenal ulcer.
To determine whether the problem is currently active, the nurse should assess the client
for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
ACTUAL EXAM | 100% VERIFIED TEST BANK 2025
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. -
E. Answer-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. -
F. Answer-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 -
G. Answer-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 -
5. Answer-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 -
G. Answer-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 -
Answer-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 -
Answer-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. -
Answer-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 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 diagnosed Crohn's
disease about dietary measures to implement during exacerbation episodes. Which
statement made by the client indicates a need for further instruction?
A. "I should increase the fiber in my diet."
B. "I will need to avoid caffeinated beverages."
C. "I'm going to learn some stress reduction techniques."
D. "I can have exacerbations and remissions with Crohn's disease." -
Answer-A. "I should increase the fiber in my diet."
Rationale:
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 narrowed
lumen, fistulas, ulcerations, and abscesses. It is characterized by exacerbations and remissions. If
stress increases the symptoms of the disease, the client is taught stress management techniques
and may require additional counseling. The client is taught to avoid gastrointestinal stimulants
containing caffeine and to follow a high-calorie and high-protein 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 history of duodenal ulcer.
To determine whether the problem is currently active, the nurse should assess the client
for which sign(s)/symptom(s) of duodenal ulcer?
A. Weight loss
B. Nausea and vomiting
