NCLEX-PN
Gastrointestinal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
Question 2 of 5
The client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast-food restaurant. Which intervention should be implemented first?
Correct Answer: C
Rationale: Drawing a CBC assesses for infection or anemia due to bloody stools, guiding treatment. Stool samples, antibiotics, and antidiarrheals follow assessment.
Question 3 of 5
The nurse is assessing the client recovering from abdominal surgery who has a patient-controlled analgesia (PCA) pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Determining PCA use assesses if overmedication is causing shallow respirations, guiding further action. Insisting on breathing, x-rays, or oxygen are secondary without cause.
Question 4 of 5
The nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?
Correct Answer: C
Rationale: The perineal incision must be examined frequently to assess for drainage and the need for dressing changes.
Question 5 of 5
A client is found to have colon cancer. An abdominoperineal resection and colostomy are scheduled. Neomycin is ordered. The nurse explains to the client that the primary purpose for administering this drug is to:
Correct Answer: B
Rationale: Neomycin, a poorly absorbed antibiotic, reduces bacterial content in the colon to prevent postoperative infections like peritonitis.