NCLEX REVIEW GI Saunders

NCLEX REVIEW GI Saunders 1.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 surgery as soon

as possible.

• Reposition the client and apply a heating pad on the warm setting

to the client's abdomen.

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.

2.A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.a.Diarrhiea b.Black, tarry stools c.Hyperactive bowel sounds d.Gray-blue color at the flank e.Abdominal guarding and tenderness f.Left upper quadrant pain with radiation to the back

Rationale:

Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

3.The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.a.Fever b.Positive Cullen’s sign c.Complaints of indigestion d.Palpable mass in the left upper quadrant e.Pain in the upper right after a fatty meal f.Vague lower right quadrant abdominal discomfort

Rationale:

During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.

4.A client is diagnosed 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?a.Select foods high in fat.b.Increase intake of fluids, including juices.c.Eat a good supper when anorexia is not as severe.d.Eat less often, preferably only 3 large meals daily.

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.

5.A client has developed hepatitis A after eating contaminated oysters.

The nurse assesses the client for which expected assessment finding?a.Malaise b.Dark stools c.Weight gain d.Left upper quadrant discomfort

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.

6.The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?a."I have had unprotected sex with multiple partners." b."I ate shellfish about 2 weeks ago at a local restaurant." c."I was an intravenous drug abuser in the past and shared needles." d."I had a blood transfusion 30 years ago after major abdominal surgery."

Rationale:

Hepatitis A is transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids, such as in the cases of intravenous drug abuse, history of blood transfusion, or unprotected sex with multiple partners.

7.The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.a.Maintain NPO (nothing by mouth) status.b.Encourage coughing and deep breathing.c.Give small, frequent high-calorie feedings.d.Maintain the client in a supine and flat position.e.Give hydromorphone intravenously as prescribed for pain.f.Maintain intravenous fluids at 10 mL/hour to keep the vein open.

Rationale:

The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions

that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

8.The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?Inability to pass flatus Loss of anal sphincter control Severe, constant pain with rapid onset Firm, nontender mass palpable at the lower right costal margin

Rationale:

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis.Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

9.The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful?a.Fresh Fruit b.Brown Gravy c.Fresh vegetables d.Poultry without skin

Rationale:

The client with cholecystitis should decrease overall intake of dietary fat.Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

10.The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis?a."Does the pain in your stomach radiate to your back?"