NCLEX-PN
Gastrointestinal NCLEX Questions Questions
Extract:
Question 1 of 5
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
Question 2 of 5
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.
Question 3 of 5
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
Question 4 of 5
After Billroth II surgery (gastrojejunostomy), the client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high-carbohydrate meal. The nurse should interpret that these symptoms indicate the development of which problem?
Correct Answer: D
Rationale: A. Although steatorrhea may occur after gastric resection, the symptoms of steatorrhea include fatty stools with a foul odor, not these symptoms. B. The symptoms of duodenal reflux are abdominal pain and vomiting, not these symptoms. Duodenal reflux is not associated with food intake. C. Symptoms of fluid overload would include increased BP, edema, and weight gain, not these symptoms. D. When eating large amounts of carbohydrates at a meal, the rapid glucose absorption from the chime results in hyperglycemia. This elevated glucose stimulates insulin production, which then causes an abrupt lowering of the blood glucose level. Hypoglycemic symptoms of weakness, diaphoresis, anxiety, and palpitations occur.
Question 5 of 5
The nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD?
Correct Answer: A
Rationale: Pyrosis (heartburn), water brash (regurgitation of sour fluid), and flatulence are classic symptoms of GERD due to acid reflux and gas buildup. The other options include symptoms more associated with other conditions like peptic ulcer disease or systemic disorders.