NCLEX-PN
Gastrointestinal NCLEX Questions Questions
Extract:
Question 1 of 5
The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.
Question 2 of 5
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.
Question 3 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 4 of 5
The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement?
Correct Answer: D
Rationale: Removing the dressing to assess the source of red drainage (e.g., bleeding or dehiscence) is critical for timely intervention. Other actions are secondary to identifying the cause.
Question 5 of 5
The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?
Correct Answer: A
Rationale: Hot, soapy showers can worsen pruritus by drying the skin, requiring intervention. Emollients, mittens (to prevent scratching), and patting dry are appropriate.