The nurse is discharging the client after Billroth II surgery (gastroj

NCLEX Questions Gastrointestinal System

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Question 1 of 5.

The nurse is discharging the client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, which information should the nurse include in the client's discharge instructions?

A. Drink plenty of fluids with all your meals.

B. Eat a high-carbohydrate, low-protein diet

C. Wait to eat at least 5 hours between meals.

D. Lie down for 20 to 30 minutes after meals.

Explanation: A. Drinking fluids at mealtime increases the size of the food bolus that enters the stomach. B. Carbohydrates are more rapidly digested than fats and proteins and would cause the food bolus to pass quickly into the intestine, increasing the likelihood that dumping syndrome would occur. Meals high in carbohydrates result in postprandial hypoglycemia, which is considered a variant of dumping syndrome. C. Small, frequent meals are recommended to decrease dumping syndrome. D. Lying down after meals slows the passage of the food bolus into the intestine and helps to control dumping syndrome.

Question 2 of 5.

The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?

A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.

B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.

C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.

D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.

Explanation: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.

Question 3 of 5.

Which statement made by the client indicates to the nurse the client may be experiencing GERD?

A. My chest hurts when I walk up the stairs in my home.

B. I take antacid tablets with me wherever I go.

C. My spouse tells me I snore very loudly at night.

D. I drink six (6) to seven (7) soft drinks every day.

Explanation: Frequent use of antacids suggests ongoing heartburn or reflux symptoms, a hallmark of GERD. Chest pain with exertion is more suggestive of cardiac issues, snoring may indicate sleep apnea, and soft drink consumption is a risk factor but not a direct symptom.

Question 4 of 5.

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?

A. Notify the health-care provider (HCP).

B. Assess the client for muscle weakness.

C. Request telemetry for the client.

D. Prepare to administer potassium IV.

Explanation: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.

Question 5 of 5.

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?

A. My stoma should be pink and moist.

B. I will irrigate my ileostomy every morning.

C. If I get a red, bumpy, itchy rash I will call my HCP.

D. I will change my pouch if it starts leaking.

Explanation: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.