NCLEX-PN
Gastrointestinal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
Question 2 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 3 of 5
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
Question 4 of 5
The client has an eviscerated abdominal wound. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Applying a sterile normal saline dressing keeps the eviscerated wound moist and protected until surgical repair. Replacing organs is contraindicated, reverse Trendelenburg is incorrect, and antibiotics are secondary.
Question 5 of 5
Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.