Exam (elaborations)
NUR 1212C Exam 3 Review Questions
- Course
- NUR 1212C
- Institution
- Florida State College At Jacksonville
This document contains detailed practice questions and answers for Exam 3. *Essential Study Material!!
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Chapter 48. Gastrointestinal Problems Practice Questions529. 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?
1. Administer the prescribed pain medication.
2. Notify the primary health care provider (PHCP).
3. Call and ask the operating room team to perform surgery as soon as possible.
4. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
529. Answer: 2
Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis
and notify the PHCP. 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 PHCP probably would perform the
surgery earlier than the prescheduled time.
530. 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.
icon01-9780323358415 1. Diarrhea
icon01-9780323358415 2. Black, tarry stools
icon01-9780323358415 3. Hyperactive bowel sounds
icon01-9780323358415 4. Gray-blue color at the flank
icon01-9780323358415 5. Abdominal guarding and tenderness
icon01-9780323358415 6. Left upper quadrant pain with radiation to the back
530. Answer: 4, 5, 6
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.
531. 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.
icon01-9780323358415 1. Fever
icon01-9780323358415 2. Positive Cullen’s sign
icon01-9780323358415 3. Complaints of indigestion
icon01-9780323358415 4. Palpable mass in the left upper quadrant
icon01-9780323358415 5. Pain in the upper right quadrant after a fatty meal
icon01-9780323358415 6. Vague lower right quadrant abdominal discomfort
531. Answer: 1, 3, 5
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.
532. 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?
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 3 large meals daily.
532. 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 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.
533. A client has developed hepatitis 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
533. Answer: 1
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.
534. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client?
Select all that apply.
icon01-9780323358415 1. Administer stool softeners as prescribed.
icon01-9780323358415 2. Instruct the client to limit fluid intake to avoid urinary retention.
icon01-9780323358415 3. Encourage a high-fiber diet to promote bowel movements without straining.
icon01-9780323358415 4. Apply cold packs to the anal-rectal area over the dressing until the packing is
removed.
icon01-9780323358415 5. Help the client to a Fowler’s position to place pressure on the rectal area and
decrease bleeding.
534. Answer: 1, 3, 4
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 and 5 are incorrect interventions.
535. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to
avoid. Which items should the nurse include on this list? Select all that apply.
icon01-9780323358415 1. Coffee
icon01-9780323358415 2. Chocolate
icon01-9780323358415 3. Peppermint
icon01-9780323358415 4. Nonfat milk
icon01-9780323358415 5. Fried chicken
icon01-9780323358415 6. Scrambled eggs
535. 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 GERD and therefore should be avoided. Aggravating
substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol.
Options 4 and 6 do not promote this effect.
536. 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 temperature
2. Monitoring complaints of heartburn
, 3. Giving warm gargles for a sore throat
4. Assessing for the return of the gag reflex
536. Answer: 4
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.
537. The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography
(ERCP) procedure. The nurse determines that the client needs further information if the client makes which
statement?
1. “I know I must sign the consent form.”
2. “I hope the throat spray keeps me from gagging.”
3. “I’m glad I don’t have to lie still for this procedure.”
4. “I’m glad some intravenous medication will be given to relax me.”
537. Answer: 3
Rationale: The client does have to lie still for 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.
538. The primary health care provider has determined that a client has contracted hepatitis A based on flu-like
symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
1. “I have had unprotected sex with multiple partners.”
2. “I ate shellfish about 2 weeks ago at a local restaurant.”
3. “I was an intravenous drug abuser in the past and shared needles.”
4. “I had a blood transfusion 30 years ago after major abdominal surgery.”
538. Answer: 2
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.
539. 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?
1. Clamp the T-tube.
2. Irrigate the T-tube.
3. Document the findings.
4. Notify the primary health care provider.
539. Answer: 3
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.
540. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most
likely indicate perforation of the ulcer?
1. Bradycardia
2. Numbness in the legs
3. Nausea and vomiting
4. A rigid, board-like abdomen
540. Answer: 4
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