NCLEX-PN
NCLEX Questions Gastrointestinal System Questions
Extract:
Question 1 of 5
The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
Question 2 of 5
The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which healthcare provider's order should the nurse question?
Correct Answer: A
Rationale: An NG tube is not routinely needed for acute diverticulitis unless there is vomiting or obstruction, which is not indicated. IV fluids, clear liquids, and bedrest are standard to rest the bowel and manage inflammation.
Question 3 of 5
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.
Question 4 of 5
The client had Billroth II surgery 24 hours ago. The client’s son approaches the nurse in the hallway and asks for information regarding his father’s condition. The wife is listed as the designated contact person. Which nurse response is best?
Correct Answer: B
Rationale: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client’s room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.
Question 5 of 5
The client is one (1) day postoperative major abdominal surgery. Which client problem is priority?
Correct Answer: B
Rationale: Fluid and electrolyte imbalance is the priority due to risks of dehydration or imbalances from surgery, impacting hemodynamic stability. Skin integrity, bowel elimination, and body image are secondary in the immediate postoperative period.