NCLEX-RN
Gastrointestinal Disorders NCLEX RN Questions
Extract:
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit cares for a client who is postoperative
Item 1 of 1
Progress Notes
Day 2
Status-post open (partial) gastrectomy. Client reports abdominal pain 6/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is taut with hypoactive bowel sounds in all quadrants. Reports passing no flatus. Endorses occasional nausea with no vomiting. Incision approximated with moderate serosanguinous drainage. Abnormal laboratory data noted: BUN 19 mg/dL (10 – 20 mg/dL); Creatinine 1.0 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.3 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, only consuming 10-15% of meals. No VS abnormalities.
Day 3
Status-post open (partial) gastrectomy. Client reports abdominal pain 4/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is distended, with hypoactive bowel sounds in all quadrants. Reports passing no flatus and is hiccuping during the exam. Endorses persistent nausea and occasional vomiting with no relief from prescribed ondansetron. Incision approximated with scant serosanguinous drainage. Abnormal laboratory data noted: BUN 23 mg/dL (10 – 20 mg/dL); Creatinine 1.3 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.1 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, nursing reports 0% consumption of meals. VS showed an oral temperature of 99.5°F (37.5°C).
Question 1 of 5
The client is at highest risk for [condition] as evidenced by the client's............and............
Correct Answer: A,C
Rationale: Paralytic ileus (
A) is evidenced by hypoactive bowel sounds, no flatus, and hypokalemia (
C), as low potassium (3.1 mEq/L) can contribute to ileus post-gastrectomy.
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Question 2 of 5
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Question 4 of 5
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Question 5 of 5
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