NCLEX-PN
Gastrointestinal NCLEX Questions
Extract:
Question 1 of 5
The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?
Correct Answer: D
Rationale: Tachycardia (pulse 104) and low BP (98/60) suggest possible bleeding or hypovolemia post-colonoscopy, requiring immediate intervention. A soft abdomen, watery stool, and hyperactive bowel sounds are expected.
Question 2 of 5
The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
Question 3 of 5
The client has a nasogastric tube. The healthcare provider orders IV fluid replacement based on the previous hour's output plus the baseline IV fluid ordered of 125 mL/hr. From 0800 to 0900 the client's N/G tube drained 45 mL. At 0900, what rate should the nurse set for the IV pump?
Correct Answer: 170 mL/hr
Rationale: Baseline IV fluid is 125 mL/hr, plus 45 mL NG output = 125 + 45 = 170 mL/hr.
Question 4 of 5
The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?
Correct Answer: B
Rationale: Monitoring blood pressure detects complications of portal hypertension, like variceal bleeding. Tympanic wave is incorrect, liver percussion is less urgent, and weight checks are secondary.
Question 5 of 5
The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis?
Correct Answer: C
Rationale: Crohn's disease often causes alternating diarrhea and constipation due to inflammation and strictures throughout the GI tract. Pain relief after bowel movements is less specific, bright red blood is more typical of ulcerative colitis, and a rigid abdomen suggests complications.