NCLEX-RN: GI Practice Questions

NCLEX-RN: GI Practice Questions

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX-RN Exam Preview 113 terms lalaitsdestinee Preview Med Surg Gastrointestinal NCLEX Q...86 terms Jasmine_Lawson4 Preview GI Evov 46 terms sno 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?

• Notify the health care provider (HCP)
• Administer the prescribed pain medication
• Call and ask the the operating room team to perform

surgery as soon as possible.

• Reposition the client and apply a heating pad on the

warm setting tot he client's abdomen.

• Notify the health care provider (HCP)

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.During preparation for bowel surgery, a male client receives an antibiotic to reduce intestinal bacteria.Antibiotic therapy may interfere with synthesis of which vitamin and may lead to hypoprothrombinemia?

• vitamin A
• vitamin D
• vitamin E
• vitamin K
• vitamin K

Rationale: Vitamin K is synthesized by bacterial flora, deficiency in this vitamin can lead to bleeding tendencies

When evaluating a male client for complications of acute

pancreatitis, the nurse would observe for:

• increased intracranial pressure.
• decreased urine output.
• bradycardia.
• hypertension.
• decreased urine output.

Rationale: Pancreatitis can lead to fatal hemorrhaging, decreased urine output

may indicate internal bleeding.A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially?

• Lying on the right side with legs straight
• Lying on the left side with knees bent
• Prone with the torso elevated
• Bent over with hands touching the floor
• Lying on the left side with knees bent

Rationale: this is the ideal/recommended position for the procedure.

A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been "spitting up blood." A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client's wife. The question by the nurse that demonstrates

her understanding of Mallory-Weiss tearing is:

• "Tell me about your husband's alcohol usage."
• "Is your husband being treated for tuberculosis?"
• "Has your husband recently fallen or injured his chest?"
• "Describe spices and condiments your husband uses

on food."

• “Has your husband recently fallen or injured his chest?”

Rationale: this condition is commonly associated with blunt abdominal trauma.

Other risk factors include, prolonged vomiting, retching and coughing. Primal scream therapy.Which of the following nursing interventions should the nurse perform for a female client receiving enteral feedings through a gastrostomy tube?

• Change the tube feeding solutions and tubing at least

every 24 hours.

• Maintain the head of the bed at a 15-degree elevation

continuously.

• Check the gastrostomy tube for position every 2 days.
• Maintain the client on bed rest during the feedings.
• Change the tube feeding solutions and tubing at least every 24 hours.

Rationale: Elevation must be at least 30-45 degrees when on bed. Position is not checked since this is surgically placed, residual is still monitored. Patient should be upright during feedings The nurse is caring for a male client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

• Dyspnea and fatigue
• Ascites and orthopnea
• Purpura and petechiae
• Gynecomastia and testicular atrophy
• Purpura and petechiae

Rationale: deficiency in this vitamin can lead to bleeding tendencies.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit?

• Appendicitis
• Pancreatitis
• Cholecystitis
• Gastric ulcer
• Pancreatitis

Rationale: Potential for bleeding internally and the inability to tolerate any form of oral intake.Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

• Endoscopy
• Upper GI series
• Hemoglobin (Hb) levels and hematocrit (HCT)
• Arteriography
• Hemoglobin (Hb) levels and hematocrit (HCT)

Rationale: Hemodynamic stability is assessed first in any confirmed case of GI

bleed.When preparing a male client, age 51, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

• Obstruction of the appendix may increase venous

drainage and cause the appendix to rupture.

• Obstruction of the appendix reduces arterial flow,

leading to ischemia, inflammation, and rupture of the appendix.

• The appendix may develop gangrene and rupture,

especially in a middle-aged client.

• Infection of the appendix diminishes necrotic arterial

blood flow and increases venous drainage.

• Obstruction of the appendix reduces arterial flow, leading to ischemia,

inflammation, and rupture of the appendix.

• To prevent gastroesophageal reflux in a male client

with hiatal hernia, the nurse should provide which discharge instruction?

• "Lie down after meals to promote digestion."
• "Avoid coffee and alcoholic beverages."
• "Take antacids with meals."
• "Limit fluid intake with meals."
• “Avoid coffee and alcoholic beverages.”

Rationale: Acidic food, caffeine, alcohol and tobacco products should be

avoided. Patient should always stay well hydrated.The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?

• Administering pain medication
• Obtaining a blood sample for laboratory studies
• Preparing to insert a nasogastric (NG) tube
• Administering I.V. fluids
• Preparing to insert a nasogastric (NG) tube

Rationale: GI rest will take the highest priority. NGT for decompression and

placing the client on NPO will be done first

A male client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond?

• Notify the physician
• Reposition the tube
• Check the tube for kinks
• Increase the suction level
• Check the tube for kinks

Rationale: Assessment before interventions.

• What laboratory finding is the primary diagnostic

indicator for pancreatitis?

• Elevated blood urea nitrogen (BUN)
• Elevated serum lipase
• Elevated aspartate aminotransferase (AST)
• Increased lactate dehydrogenase (LD)
• Elevated serum lipase

Rationale: Lipase is the best indicator for pancreatitis.

A male client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the

nurse expects to note:

• yellow sclera.
• light amber urine.
• severe RUQ pain
• black, tarry stools.
• severe RUQ pain

Rationale: Pain is the classic sign for biliary obstruction accompanied by nausea and vomiting. Yellow sclera, tea colored urine and jaundice are later signs if the condition does not resolve.Nurse Hannah is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for

peptic ulcers, the nurse should mention:

• a sedentary lifestyle and smoking.
• a history of hemorrhoids and smoking.
• alcohol abuse and a history of acute renal failure.
• alcohol abuse and smoking.
• alcohol abuse and smoking.

Rationale: Option D has two major risk factors. The other options only one risk

factor.

• While palpating a female client's right upper quadrant

(RUQ), the nurse would expect to find which of the following structures?

• Sigmoid colon
• Appendix
• Spleen
• Liver
• Liver

A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs.

The nurse's first response is to:

• call the physician.
• place saline-soaked sterile dressings on the wound.
• take a blood pressure and pulse.
• pull the dehisced wound to close.
• place saline-soaked sterile dressings on the wound.

Rationale: Keeping the site moist with a sterile dressing soaked in saline is the recommended first aid for eviscerated organs. Then call the physician for an emergency repair. Manipulating the site is contraindicated.