NCLEX-PN
NCLEX Questions Gastrointestinal System Questions
Question 1 of 5
Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery?
Correct Answer: D
Rationale: Pain (alteration in comfort) is the highest priority post-cholecystectomy, as it affects recovery and mobility. Nutrition, skin, and urinary issues are secondary in the immediate postoperative period.
Question 2 of 5
The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse?
Correct Answer: D
Rationale: Refusal to turn, deep breathe, and cough increases the risk of atelectasis and pneumonia post-surgery, requiring immediate intervention. Absent bowel sounds, T-tube drainage, and urine output are expected at this stage.
Question 3 of 5
The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client’s anxiety?
Correct Answer: D
Rationale: A. The client will not be at risk for colon cancer because with a total colectomy the entire colon is removed. B. Since this surgery removes the total colon, the ulcerative colitis will be cured. C. The client will be unable to eat until peristalsis returns, and then it may take several days before solid foods are tolerated. D. The client will initially have an ileostomy; after the reservoir has healed, the ileostomy will be closed. Knowing that the ileostomy will be temporary is important information for the client to decrease anxiety.
Question 4 of 5
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
Correct Answer: B
Rationale: The semi-sitting position promotes gravity-dependent drainage through the Penrose drain from the abdominal cavity.
Question 5 of 5
The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.