Download MED SURG GASTROINTESTINAL NCLEX QUESTIONS AND ANSWERS LATEST VERSION VERIFIED RATIONALE GR and more Exams Nursing in PDF only on Docsity!
AND ANSWERS LATEST VERSION VERIFIED
RATIONALE GRADED A+
A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record? A. Apply a cold pack to the abdomen. B. Administer 30 mL of milk of magnesia (MOM). C. Maintain nothing by mouth (nil per os [NPO]) status. D. Initiate an intravenous (IV) line for the administration of IV fluids. - ansB. Administer 30 mL of milk of magnesia (MOM). Rationale: Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery. A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain. Appendicitis is suspected, and appropriate laboratory tests are performed. The emergency department nurse reviews the test results and notes that the client's white blood cell (WBC) count is elevated. The nurse also reviews the prescriptions from the health care provider (HCP). The nurse should contact the HCP to question which prescription if noted in the client's record? A. Maintain a semi Fowler's position. B. Maintain on NPO (nothing by mouth) status. C.Apply a heating pad to the lower abdomen for comfort. D. Initiate an intravenous (IV) line with the administration of IV fluids. - ansC.Apply a heating pad to the lower abdomen for comfort. Rationale: Appendicitis should be suspected in a client with an elevated WBC count who is complaining of acute right lower quadrant abdominal pain. A semi Fowler's position is maintained for comfort. The client
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RATIONALE GRADED A+
would be on NPO status and given IV fluids in preparation for possible surgery. Heat should never be applied to the abdomen because this may increase circulation to the appendix, potentially leading to increased inflammation and perforation. A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? A. "I eat at least 3 large meals each day." B. "I eat while lying in a semirecumbent position." C. "I have eliminated taking liquids with my meals." D. "I eat a high-protein, low- to moderate-carbohydrate diet." - ansA. "I eat at least 3 large meals each day." Rationale: Dumping syndrome describes a group of symptoms that occur after eating. It is believed to result from rapid dumping of gastric contents into the small intestine, which causes fluid to shift into the intestine. Signs and symptoms of dumping syndrome include diarrhea, abdominal distention, sweating, pallor, palpitations, and syncope. To manage this syndrome, clients are encouraged to decrease the amount of food taken at each sitting, eat in a semirecumbent position, eliminate ingesting fluids with meals, and avoid consumption of high-carbohydrate meals. A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation. - ansA. This is a normal, expected event. Rationale:
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RATIONALE GRADED A+
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. 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? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance - ansD. Fluid and electrolyte imbalance Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. 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 a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. 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 - ans4. Assessing for the return of the gag reflex
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RATIONALE GRADED A+
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. A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which nursing response is most appropriate at this time? A. "Do you want to stay here in this facility for a few more days?" B. "Have you discussed your feelings with your health care provider?" C. "You need to talk to your health care provider about these concerns." D. "Tell me more about your concerns with your diet after going home." - ansD. "Tell me more about your concerns with your diet after going home." Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about.. ." often leads to valuable information about the client and his concerns. The statements in the remaining options are nontherapeutic. A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? A. NPO (nothing by mouth) status B. Ambulation at least 4 times daily C. Cholinergic medications to reduce pain D. Coughing and deep breathing every 2 hours - ansA. NPO (nothing by mouth) status
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RATIONALE GRADED A+
Rationale: Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action should be the priority for this client? A. Assessment of vital signs B. Complete abdominal examination C. Thorough investigation of precipitating events D. Insertion of a nasogastric tube and Hematest of emesis - ansA. Assessment of vital signs Rationale: The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? A. Discontinue the enema. B. Reassure the client, and continue the flow. C. Raise the enema bag so that the solution can be completed quickly. D. Clamp the tubing for 30 seconds, and restart the flow at a slower rate. - ansD. Clamp the tubing for 30 seconds, and restart the flow at a slower rate. Rationale:
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RATIONALE GRADED A+
Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, the actions in the remaining options are incorrect. A client who has been advanced to a solid diet after undergoing a subtotal gastrectomy. What is the appropriate nursing intervention in preventing dumping syndrome? A. Remove fluids from the meal tray. B. Give the client 2 large meals per day. C. Ask the client to sit up for 1 hour after eating. D. Provide concentrated, high-carbohydrate foods. - ansA. Remove fluids from the meal tray. Rationale: Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small, frequent meals; having the client maintain a low Fowler's position while eating, if possible; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications also are prescribed as needed to delay gastric emptying. A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? A. Call the surgeon to report the problem. B. Reposition the NG tube to the proper location. C. Check the suction device to make sure it is working. D. Irrigate the NG tube with saline to remove the obstruction. - ansC. Check the suction device to make sure it is working. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working
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RATIONALE GRADED A+
A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? A. Carrots and ranch dip B. Whole-grain cereal and milk C. A cup of popcorn and a cola drink D. Applesauce and a graham cracker - ansD. Applesauce and a graham cracker Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose- containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol. A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system? A. Ileum B. Cecum C. Rectum D. Jejunum - ansB. Cecum Rationale: The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect. A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? A. "I know I can massage my abdomen."
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RATIONALE GRADED A+
B. "I will continue using antispasmodic medication." C. "One of the best things I can do is use relaxation techniques." D. "The best position for me is to lie supine with my legs straight." - ansD. "The best position for me is to lie supine with my legs straight." Rationale: Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched. A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? A. Ibuprofen B. Indomethacin C. Acetaminophen D. Naproxen sodium - ansC. Acetaminophen Analgesics, such as acetaminophen, are unlikely to cause epigastric distress. Ibuprofen, indomethacin, and naproxen sodium are nonsteroidal antiinflammatory medications (NSAIDs) and are irritating to the gastrointestinal tract, so they should be avoided in clients with gastritis. 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? A. Lying recumbent following meals B. Consuming small, frequent, bland meals C. Taking H2-receptor antagonist medication
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RATIONALE GRADED A+
C. On an empty stomach D. 30 minutes before meals - ansB. After meals Rationale: Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that in this disorder because the stomach lining produces a decreased amount of a substance known as the intrinsic factor, the client will need which medication? A. Vitamin B12 injections B. Vitamin B6 injections C. An antibiotic D. An antacid - ansA. Vitamin B12 injections Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 is a feature of pernicious anemia. Vitamin B is needed for the maturation of red blood cells. Vitamin B6 is not specifically lacking in pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers. After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? A. Stroke B. Pernicious anemia C. Bacterial meningitis
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RATIONALE GRADED A+
D. Peripheral arterial disease - ansB. Pernicious anemia Rationale: Billroth I surgery involves removing one half to two thirds of the stomach and reanastomosing the remaining segment of the stomach to the duodenum. With the loss of this much of the stomach, development of pernicious anemia is not uncommon. Pernicious anemia is a macrocytic anemia that most commonly is caused by the lack of intrinsic factor. During a Billroth I procedure, a large portion of the parietal cells, which are responsible for producing intrinsic factor (a necessary component for vitamin B12 absorption), are removed. In this anemia, the red blood cell is larger than usual and hence does not last as long in the circulation as normal red blood cells do, causing the client to have anemia with resultant fatigue. Vitamin B12 also is necessary for normal nerve function. Because of the lack of the necessary intrinsic factor, persons with pernicious anemia also experience paresthesias, impaired gait, and impaired balance. Although the symptoms could possibly indicate the other options listed, pernicious anemia is the most logical based on the surgery the client underwent. Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication? A. Decreased diarrhea B. Decreased cramping C. Improved intestinal tone D. Elimination of peristalsis - ansA. Decreased diarrhea Rationale: Diphenoxylate hydrochloride with atropine sulfate is an antidiarrheal product that decreases the frequency of defecation, usually by reducing the volume of liquid in the stools. The remaining options are not associated therapeutic effects of this medication. During a home care visit, an adult client complains of chronic constipation. What should the nurse tell the client to do? A. Increase potassium in the diet.
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RATIONALE GRADED A+
D. "It will help to remove gas and fluids from my stomach and intestine." - ansD. "It will help to remove gas and fluids from my stomach and intestine." Rationale: Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the stomach and bowel. Continuous gastric suction does not provide nourishment. The purpose of tracheal suctioning (not gastric suctioning) is to remove excess mucus that has led to congestion. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction. The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client that which of these medications are not a part of the treatment plan because of its irritating effects on the lining of the gastrointestinal tract? A. Nizatidine B. Sucralfate C. Ibuprofen D. Omeprazole - ansC. Ibuprofen Rationale: Ibuprofen is a nonsteroidal antiinflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H2-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor that blocks transport of hydrogen ions into the lumen of the gastrointestinal tract. The nurse cares for a client following a Roux-en-Y gastric bypass surgery. Which nursing intervention is appropriate? A. Encourage the client to ambulate. B. Position the client on the left side.
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RATIONALE GRADED A+
C. Frequently irrigate the nasogastric tube (NG) with 30 mL saline. D. Discourage the use of the patient-controlled analgesia (PCA) machine. - ansA. Encourage the client to ambulate. Rationale: Bariatric clients are at risk for developing deep vein thrombosis and atelectasis. It is important to encourage ambulation to promote both venous return in the legs and lung expansion. Therefore, the correct option is 1. Option 2 is incorrect, as positioning on the left side is not indicated and positioning on the right side would be more appropriate to facilitate gastric emptying. Option 3 is incorrect, as the stomach after a Roux-en-Y procedure is very small and often holds only 30 mL, so frequent irrigation with 30 mL could lead to disruption of the anastomosis or staple line. Option 4 is incorrect because clients who have gastric bypass surgery are often in a considerable amount of pain and it is important for their pain to be controlled so that they are able to do the activities required, such as coughing and deep breathing and ambulation, to prevent complications. The nurse caring for a client diagnosed with inflammatory bowel disease (IBD) recognizes that which classifications of medications may be prescribed to treat the disease and induce remission? Select all that apply. A. Antidiarrheal B. Antimicrobial C. Corticosteroid D. Aminosalicylate E. Biological therapy F. Immunosuppressant - ansB. Antimicrobial C. Corticosteroid D. Aminosalicylate E. Biological therapy F. Immunosuppressant Rationale:
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C. Glycerin suppository D. Soap solution enema (SSE) - ansC. Glycerin suppository Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client. The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply. A. Pull the tube back slightly. B. Instruct the client to breathe slowly. C. Assist the client to take sips of water. D. Continue to slowly advance the tube to the desired distance. E. Check the back of the pharynx using a tongue blade and flashlight. - ansA. Pull the tube back slightly. B. Instruct the client to breathe slowly. C. Assist the client to take sips of water.. E. Check the back of the pharynx using a tongue blade and flashlight. Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the
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RATIONALE GRADED A+
larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes. The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? A. "Baked foods such as chicken or fish are all right to eat." B. "Citrus fruits and raw vegetables need to be included in my daily diet." C. "I can drink beer as long as I consume only a moderate amount each day." D. "I can drink coffee or tea as long as I limit the amount to 2 cups daily." - ansA. "Baked foods such as chicken or fish are all right to eat." Rationale: Dietary modifications for the client with peptic ulcer disease include eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective? A. "It will cause diaphoresis and diarrhea." B. "I have to monitor for hiccups and diarrhea." C. "It will be associated with constipation and fever." D. "I have to monitor for fatigue and abdominal pain." - ansA. "It will cause diaphoresis and diarrhea." Rationale:
