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
Integrated Process: Nursing Process: Implementation
Content Area: Adult Health: Gastrointestinal
Strategy(ies): Abnormality Exists, Strategic Words
Priority Concepts: Clinical Judgment, Inflammation
Test-Taking Strategy:
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
,SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
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 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:
, SAUNDERS - GI QUESTIONS AND ANSWERS UPDATED
2024/2025 ALL ANSWERS 100% CORRECT VERIFIED BEST
GRADED TO SCORE A+ FOR SUCCESS
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
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.
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