NCLEX-RN EXAM Gastrointestinal System

NCLEX-RN EXAM Gastrointestinal System

617) 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? - 1) Burning and aching, located in the left lower quadrant radiating to the hip 2) Severe unrelenting, located in the epigastric area and radiating to the back 3) Burning and aching, located in the epigastric area and radiating to the umbilicus 4) Severe and unrelenting, located in the left lower quadrant and radiating to the groin

ANSWER: 1

Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Heat should never be applied to the abdomen of a client with a suspected appendicitis because of the risk of rupture. Scheduling surgery time is not within the scope of nursing practice.

619) The nurse is assessing a client who is experiencing an acute episode of choleycytitis. Where should the nurse anticipate the location of the pain? - 1) Right lower quadrant, radiating to the back 2) Right lower quadrant, radiating to the umbilicus 3) Right upper quadrant radiating to the left scapula and shoulder 4) Right upper quadrant, radiating to the right scapula and shoulder

ANSWER: 4

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 dermatones in the body

620) 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? - 1) Select foods high in fat 2) Increase intake of fluids, including juices 3) Eat a good supper when anorexia is not as severe 4) Eat less often, preferably only three large meals daily

ANSWER: 2

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 the 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 3000mL day that includes nutritional juices are also important

621) A client has developed Hepititis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? - 1) Malaise 2) Dark stools 3) Weight gain

4) Left upper quadrant discomfort

ANSWER: ANSWER: 1

Rationale: Hepititis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light, clay colored if conjugated bilirubin is unable to flow out of the liver due to the inflammation or obstruction of the bile ducts

622) A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply - 1) Administer stool softners as prescribed 2) Instruct the client to limit fluid intake to avoid urinary retention 3) Instruct the client to avoid activities that will initiate vasovagal responses 4) Encourage a high fiber diet to promote bowel movements without straining 5) Apply cold packs to the anal rectal area over the dressing until the packing is removed 6) Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

ANSWER: 1, 4, 5

Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding and incision rupture. Stool softners and 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

623) The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on this list? Select all that apply - 1) Coffee 2) Chocolate 3) Peppermint 4) Nonfat milk 5) Fried chicken 6) Scrambled eggs

ANSWER: 1,2, 3, 5

Rationale: Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophagel reflux disease (GERD) and therefore should be avoided. Aggravating substances include chocolate, coffee, friend or fatty foods, peppermint, carbonated beverages, and alcohol.

624) 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 temp 2) Monitoring complaints of heartburn 3) Giving warm gargles for a sore throat 4) Assessing for the return of the gag reflux

ANSWER: 4

Rationale: The nurse places the highest priority on assessing for the 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 gastrointestinal tract. This

complication would be accompanied by other signs as well, such as main. Monitoring for sore throat and heart burn are important, but airway is the priority.

627) The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this is at risk for which vitamin deficiency? - 1) Vitamin A 2) Vitamin B12 3) Vitamin C 4) Vitamin E

ANSWER: 2

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 the inability to absorb B12. This leads to the development of pernicious anemia.

629) The nurse is monitoring a client with a diagnosis of a peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? - 1) Bradycardia 2) Numbness of the legs 3) Nausea and vomiting 4) A rigid, boardlike abdomen

ANSWER: 4

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.

631) The nurse is providing discharge instructions to a client following a gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? - 1) Ambulate following a meal 2) Eat high-carbohydrate foods 3) Limit the fluids taken with meals 4) Sit in a high Fowler's position during meals

ANSWER: 3

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 manifestiations usually occur within 30 min of eating including vertigo, tachycardia, syncope, sweating, pallor, and the desire to lie down. The nurse should instruct the patient to decrease the amount of fluid taken at meals and to avoid high carbohydrate foods, including fluids such a fruit nectors, to assume a low Fowler's position during meals, to lie down for 30 min after eating to delay gastric emptying, and to take antispasmodics as prescribed.

633) The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? - 1) Diarrhea 2) Chronic constipation 3) Constipation alternating with diarrhea

4) Stool constantly oozing from the rectum

ANSWER: 1

Rationale: Crohn's disease is characterized of nonbloody diarrhea usually not more than 4 to 5 stools daily. Over time, it increases in frequency, duration, and severity

636) The nurse is doing an assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should asses the client for which symptoms? - 1) weight loss 2) nausea and vomiting 3) pain relieved by food intake 4) pain radiating down the right arm

ANSWER: 3

Rationale: A frequent symptom of duodenal ulder is pain that is relieved by food intake. These clients generally describe the pain as burning, heavy, sharp, or hungry pain that often localizes in the mid epigastric. The client does not experience weight loss or nausea and vomiting. These symptoms are more typical of a client with a gastric ulcer

637) A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? - 1) Lying recumbent following meals 2) Consuming small, frequent, bland meals 3) Raising the head of the bed on 6 inch blocks 4) Taking H2 receptor antagonist medication

ANSWER: 1

Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from the reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H2 receptors antagonists and antacids, and elevation of the thorax following meals and during sleep

640) A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery. - 1) Folate deficiency 2) Malabsoprtion of fat 3) Intestinal obstruction 4) Fluid and electrolyte imbalance

ANSWER: 4

Rationale: The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is less frequent complication. Fat malabsorption and folate deficiency are complications that occur later in the postoperative period