NCLEX-RN Gastrointestinal EAQs

The nurse assesses for which major complication in a client who has had a gastroscopy? 1 Difficulty swallowing 2 Increased gastrointestinal (GI) motility 3 Nausea with vomiting Correct 4 Abdominal distention with pain

Abdominal distention, which may be associated with pain, can indicate perforation, a complication that can lead to peritonitis. A local inflammatory response to insertion of the fiberoptic tube may result in a sore throat and dysphagia once the anesthesia wears off; difficulty swallowing is expected. Increased GI motility, together with cramping, is an expected response. Nausea with vomiting is not indicative of any particular problem in this situation.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Correct 1 Monitor for nonverbal cues of pain 2 Check the pressure dressing for bleeding 3 Assist the client to ambulate around his room 4 Irrigate the client's nasogastric tube with sterile water

Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A client with gastroesophageal reflux disease reports having difficulty sleeping at night. What should the nurse instruct the client to do? 1 Drink a glass of milk before retiring. Correct 2 Elevate the head of the bed on blocks. 3 Eliminate carbohydrates from the diet. 4 Take antacids, such as sodium bicarbonate.

Elevating the head of the bed on blocks raises the upper torso and minimizes reflux of gastric contents. Increasing the content of the stomach before lying down will aggravate the symptoms associated with gastroesophageal reflux. Eliminating carbohydrates from the diet will have no effect on the reflux of gastric contents. The effect of antacids is not long-lasting enough to promote a full night's sleep; sodium bicarbonate is not recommended as an antacid.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? 1 Presence of distention 2 Extent of weight gained 3 Amount of high-fiber food consumed Correct 4 Length of time this problem has existed

First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A client is to have gastric lavage following an overdose of acetaminophen. In which position should the nurse place the client when the nasogastric tube is being inserted? 1 Supine 2 Mid-Fowler Correct 3 High-Fowler 4 Trendelenburg

Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.

A teenager is admitted with an acute onset of right lower quadrant pain at McBurney point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? 1 Urinary retention 2 Gastric hyperacidity Correct 3 Rebound tenderness 4 Increased lower bowel motility

Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? Correct 1 "When was your last drink of vodka?" 2 "What prompts your drinking episodes?" 3 "Do you also eat when you drink?" 4 "Why do you mix the vodka with orange juice?

The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

The nurse identifies that a client who had extensive abdominal surgery appears depressed. Which nursing action is the most appropriate? Correct 1 Talking with the client and encouraging exploration of feelings 2 Asking the client's primary healthcare provider to prescribe an antidepressant medication 3 Understanding that the client's depression is an expected response to surgery 4 Reassuring the client that feelings of depression will lift after returning home

The nurse must first explore the client's feelings; an honest discussion with emphasis on concerns helps promote adjustment. Asking the client's healthcare provider to prescribe an antidepressant medication may be necessary if the depression continues. Postoperative depression is not an expected response to surgery. Reassuring the client that feelings of depression will lift after returning home is false reassurance because there is no guarantee that the depression will lift at home.

A healthcare provider explains a cystectomy and an ileal conduit for a client with invasive carcinoma of the bladder. Later the client expresses concerns about the possibility of offensive odors associated with this procedure. What is the best response by the nurse? Correct 1 "Tell me more about what you are thinking." 2 "Products are available to limit this problem." 3 "This is a problem, but the surgery is necessary." 4 "Most people who have this surgery share this same concern."

The response "Tell me more about what you are thinking" is an open-ended statement that focuses on the client's concerns and allows further verbalization of feelings. Although true, the response "This is a problem, but the surgery is necessary" may increase anxiety and cut off communication. The responses "Products are available to limit this problem" and "Most people who have this surgery share this same concern" move the focus away from the client and minimize the client's concerns.

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? 1 Any rectal cancer in the family Correct 2 All foods eaten in the past 24 hours 3 Any recent extreme emotional stress 4 An upper respiratory infection in the past 10 days

The salmonella organism thrives in warm, moist environments; all foods eaten within the last 24 hours are the most relevant data. Washing, cooking, and refrigerating food limit the growth of or eliminate the organism. Salmonellosis is unrelated to cancer. The salmonella organism, not stress, causes salmonellosis. The salmonella organism is ingested; it is not an airborne or blood-borne infection.

The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? 1 "There are no dietary restrictions because the tumor has been removed." 2 "Your diet should be low in calories to prevent taxing your diseased pancreas." 3 "Meals should be restricted in protein because of your compromised liver function." Correct 4 "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."

Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs. Clients require small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings. The response "There are no dietary restrictions because the tumor has been removed" is false reassurance. High-calorie meals are needed to provide energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.