NCLEX-PN
NCLEX Gastrointestinal Questions
Extract:
Question 1 of 5
The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.
Question 2 of 5
Which problem is most appropriate for the nurse to identify for the client with diarrhea?
Correct Answer: A
Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.
Question 3 of 5
The 25-year-old client, hospitalized with an exacerbation of distal ulcerative colitis, is prescribed mesalamine rectally via enema. The client states that an enema is disgusting and wants to know why the medication cannot be given orally. Which is the best response by the nurse?
Correct Answer: B
Rationale: A. If the client still desires a change in medication route after the rationale for rectal administration is explained, the HCP should be consulted. B. This is the nurse’s best response because it explains the purpose for administration via enema. This route delivers mesalamine (Asacol) directly to the affected area, thus maximizing effectiveness and minimizing side effects. C. Oral administration is possible, but rectal administration is preferred in distal colitis. D. Nurses cannot order medications or change medication routes without specific approval by the HCP, who is licensed to prescribe medications.
Question 4 of 5
The client diagnosed with diverticulitis is complaining of severe pain in the left lower quadrant and has an oral temperature of 100.6°F. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: Assessing the abdomen first provides critical data on tenderness, rigidity, or rebound, which could indicate complications like perforation, guiding further actions. Notification or medication follows assessment.
Question 5 of 5
The client of Chinese ethnicity has diarrhea and refuses to drink the prescribed oral hydration solution, insisting on having chicken broth instead. Which statement about clients of Chinese ethnicity should be the basis for the nurse’s intervention in this situation?
Correct Answer: A
Rationale: A. Loose stools are a yin symptom, which should be treated with foods that have yang qualities, one of which is chicken. B. There is no belief in the Chinese culture related to consuming high-protein foods. C. There is no belief in the Chinese culture related to consuming high-sodium foods. D. The Chinese do not mistrust modern medicine but may combine Western medicine and Chinese herbal medicines to treat disease.