Questions 54

NCLEX-RN

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Gastrointestinal NCLEX RN Questions Questions

Extract:

The following scenario applies to the next 1 items.
The nurse is caring for a 44-year-old male with abdominal pain and persistent nausea/vomiting.
Item 1 of 1
History of Present Illness
Abdominal pain that started one day ago following heavy alcohol use. The pain is localized to the epigastric region. Persistent nausea and vomiting were reported. Physical exam showed ecchymosis around the umbilicus and tenderness upon palpation.

Vital Signs
• Oral temperature 99.0° F (37° C)
• Pulse 119
• Respirations 22
• BP 90/58
• Pulse oximetry 95% on room air


Question 1 of 5

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two priority actions the nurse should take to address that condition, and two priority parameters the nurse should monitor to assess the client's progress.

Action to Take

Obtain a prescription of 0.9% saline bolus
Inquire about the clients alcohol drinking habits
Obtain a prescription for regular insulin
Establish peripheral intravenous (IV) access
Transport the client for an abdominal computed tomography (CT) scan.

Potential Condition

Acute Pancreatitis
Peptic Ulcer Disease
Diverticulitis
Peritonitis
Gastroenteritis.

Parameter to Monitor

Level of Consciousness (LOC)
Bowel Sounds
Vital Signs
Serum Glucose Level
Daily Weights.

Correct Answer: B: Acute Pancreatitis; A: Obtain a prescription of 0.9% saline bolus, Establish peripheral IV access; C: Vital Signs, Level of Consciousness

Rationale: Epigastric pain, nausea/vomiting, and periumbilical ecchymosis suggest acute pancreatitis (
B). Saline bolus and IV access (
A) address hypovolemia. Monitoring vital signs and LOC (
C) tracks hemodynamic stability and complications.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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