Gastrointestinal NCLEX

Extract:

Question 1 of 5

The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first?

Correct Answer: B

Rationale: Cleansing the area with soap and water immediately reduces infection risk, including hepatitis. Notification, prophylaxis, and checking status follow after initial decontamination.

Question 2 of 5

The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?

A. The client will not gain more than two (2) kg a day. B. The client will have no increase in abdominal girth. C. The client's vital signs will remain within normal limits. D. The client will receive a low-sodium diet.

Correct Answer: B

Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.

Question 3 of 5

The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy. Which behavior indicates the nurse is utilizing adult learning principles?

A. The nurse repeats the information as indicated by the client's questions. B. The nurse teaches in one session all the information the client needs. C. The nurse uses a video so the client can hear the medical terms. D. The nurse waits until the client asks questions about the surgery.

Correct Answer: A

Rationale: Repeating information based on client questions respects adult learning principles by addressing the learner’s needs and reinforcing understanding. One-session teaching, videos, or waiting for questions are less interactive.

Question 4 of 5

The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?

A. Administer an antidiarrheal medication every day and prn. B. Perform bowel training every two (2) hours. C. Administer an oil retention enema. D. Prepare for an upper gastrointestinal (UGI) series x-ray.

Correct Answer: C

Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.

Question 5 of 5

The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?

A. The client has a soft, nontender abdomen. B. The client has a loose, watery stool. C. The client has hyperactive bowel sounds. D. The client's pulse is 104 and BP is 98/60.

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.

Gastrointestinal NCLEX | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN