NCLEX Practice Questions Saunders - GI System

NCLEX Practice Questions Saunders - GI System

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Students also studied Terms in this set (26) George Brown College Nursing Save Gastrointestinal Disorders NCLEX q...17 terms Shannon_Bolton9 Preview Med Surg Gastrointestinal NCLEX Q...86 terms Jasmine_Lawson4 Preview Endocrine NCLEX questions 121 terms awebstePreview Gastroi 12 terms s64 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?

• Notify the health care provider (HCP).
• Administer the prescribed pain medication.
• Call and ask the operating room team to perform the

surgery as soon as possible.

• Reposition the client and apply a heating pad on the

warm setting to the client's abdomen.

• 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 been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis?

• Burning and aching, located in the left lower quadrant

and radiating to the hip

• Severe and unrelenting, located in the epigastric area

and radiating to the back

• Burning and aching, located in the epigastric area and

radiating to the umbilicus

• Severe and unrelenting, located in the left lower

quadrant and radiating to the groin

• Severe and unrelenting, located in the epigastric area and radiating to the back

Rationale: The pain associated with acute pancreatitis is often severe and

unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?

• Right lower quadrant, radiating to the back
• Right lower quadrant, radiating to the umbilicus
• Right upper quadrant, radiating to the left scapula and

shoulder

• Right upper quadrant, radiating to the right scapula

and shoulder

• Right upper quadrant, radiating to the right scapula and shoulder

Rationale: During an acute episode of cholecystitis, the client may complain of

severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect.A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

• Select foods high in fat.
• Increase intake of fluids, including juices.
• Eat a good supper when anorexia is not as severe.
• Eat less often, preferably only three large meals daily.
• Increase intake of fluids, including juices.

Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

• Malaise
• Dark stools
• Weight gain
• Left upper quadrant discomfort
• Malaise

Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea,

right upper quadrant discomfort, and weight loss.Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.

• Administer stool softeners as prescribed.
• Instruct the client to limit fluid intake to avoid urinary

retention.

• Instruct the client to avoid activities that will initiate

vasovagal responses.

• Encourage a high-fiber diet to promote bowel

movements without straining.

• Apply cold packs to the anal-rectal area over the

dressing until the packing is removed.

• Help the client to a Fowler's position to place pressure

on the rectal area and decrease bleeding.

• Administer stool softeners as prescribed.
• Encourage a high-fiber diet to promote bowel movements without straining.
• 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 avoid straining, thereby reducing the chances of rupturing the incision.An ice pack will increase comfort and decrease bleeding. Options 2, 3, and 6 are incorrect interventions.

The nurse is planning to teach a client with gastroesophageal reflux disease about substances to avoid. Which items should the nurse include on this list? Select all that apply.

• Coffee
• Chocolate
• Peppermint
• Nonfat milk
• Fried chicken
• Scrambled eggs
• Coffee
• Chocolate
• Peppermint
• Fried chicken

Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and

irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, fried or fatty foods, peppermint, 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?

• Monitoring the temperature
• Monitoring complaints of heartburn
• Giving warm gargles for a sore throat
• Assessing for the return of the gag reflex
• 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 has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement?

• "I know I must sign the consent form."
• "I hope the throat spray keeps me from gagging."
• "I'm glad I don't have to lie still for this procedure."
• "I'm glad some IV medication will be given to relax

me."

• "I'm glad I don't have to lie still for this procedure."

Rationale: The client does have to lie still for endoscopic retrograde

cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis A

Rationale: Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client, knowing that this client is at risk for which vitamin deficiency?

• Vitamin A
• Vitamin B12
• Vitamin C
• Vitamin E
• Vitamin B12

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. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency.The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

• Clamp the T-tube.
• Irrigate the T-tube.
• Document the findings.
• Notify the health care provider.
• Document the findings.

Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?

• Bradycardia
• Numbness in the legs
• Nausea and vomiting
• A rigid, boardlike abdomen
• 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 Billroth II procedure. Which postoperative prescription should the nurse question and verify?

• Leg exercises
• Early ambulation
• Irrigating the nasogastric tube
• Coughing and deep-breathing exercises
• Irrigating the nasogastric tube

Rationale: In a 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?

• Ambulate following a meal.
• Eat high-carbohydrate foods.
• Limit the fluids taken with meals.
• Sit in a high Fowler's position during meals.
• 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 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.