Page 1535 - Saunders Comprehensive Review For NCLEX-RN

Priority Concepts: Clinical Judgment; Infection
Reference: Ignatavicius, Workman, Rebar (2018), p. 1183.

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.
Test-Taking Strategy: Focus on the subject, postoperative hemorrhoidectomy
care. Recall that decreasing fluid intake will cause difficulty with defecation because
of hard stool. Recognize that Fowler’s position will increase pressure in the rectal
area, causing increased bleeding and increased pain.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Lower GI Disorders
Priority Concepts: Elimination; Pain
Reference: Ignatavicius, Workman, Rebar (2018), p. 1140.

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.
Test-Taking Strategy: Focus on the subject, food items to avoid. Use knowledge of
the effect of various foods on LES pressure and GERD. However, if you are unsure,
note that options 4 and 6 are the most healthful food items.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Gastrointestinal
Health Problem: Adult Health: Gastrointestinal: Upper GI Disorders
Priority Concepts: Client Education; Inflammation
Reference: Ignatavicius, Workman, Rebar (2018), pp. 1088, 1090.

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

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