SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
Saunders Comprehensive Review for the NCLEX-RN Examination 7th
Content Area -> Adult Health -> Gastrointestinal -> 171 Questions
Text -> 26 Questions - CORRECT ANSWERS
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?
a. Notify the health care provider (HCP).
b. Administer the prescribed pain medication.
c. Call and ask the operating room team to perform surgery as soon as possible.
d. Reposition the client and apply a heating pad on the warm setting to the client's
abdomen.
Source: Saunders - Adult GI - CORRECT ANSWERS ANS: A
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.
,SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
Note the strategic words, most appropriate. determine if an abnormality exists, focus on
the signs and symptoms in the question, and consider the complications that can occur
with appendicitis. Noting that the signs presented in the question indicate a
complication will assist in directing you to the correct option.
Review:
Care of the client with appendicitis
Color Key:
Cyan = Strategy
Magenta = Content Review
Reference(s):
Ignatavicius, Workman (2016), pp. 1168-1169.
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. Diarrhea
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
Source: Saunders - Adult GI - CORRECT ANSWERS ANS: D E F
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
,SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
located in the epigastric region or left upper quadrant with radiation to the back. The
other options are incorrect.
Test-Taking Strategy:
Noting that options 1 and 3 are comparable or alike will assist you in eliminating these
options first. Then recall that black, tarry stools occur when there is gastrointestinal
bleeding, so this can also be eliminated. From the remaining options, recall the
anatomical location of the pancreas, the pain characteristics, and the effect of enzymes
leaking into the tissues to direct you to the correct options.
Review:
Manifestations of acute pancreatitis
Color Key:
Cyan = Strategy
Magenta = Content Review
Reference(s):
Ignatavicius, Workman (2016), pp. 1219-1221.
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
, SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
c. Complaints of indigestion
d. Palpable mass in the left upper quadrant
e. Pain in the upper right quadrant after a fatty meal
f. Vague lower right quadrant abdominal discomfort
Source: Saunders - Adult GI - CORRECT ANSWERS ANS: A C E
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.
Test-Taking Strategy:
Focus on the subject, the location and characteristics of pain associated with
cholecystitis. Recalling the anatomical location of the gallbladder will also direct you to
the correct option.
Review:
Cholecystitis
Color Key:
Cyan = Strategy
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