NCLEX-PN
NCLEX Questions Gastrointestinal System Questions
Extract:
Question 1 of 5
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
Question 2 of 5
Following a hemorrhoidectomy, the nurse is instructing the client in self-care. Which statement is especially important to include in these instructions?
Correct Answer: A
Rationale: Washing and patting dry promotes hygiene and healing post-hemorrhoidectomy, reducing irritation.
Question 3 of 5
The nurse is preparing to administer amitriptyline 10 mg orally to the client diagnosed with IBS. The client asks, “Why am I receiving this? I don’t feel depressed.” Which response by the nurse is best?
Correct Answer: D
Rationale: A. Not all clients with chronic diseases suffer from depression. The response does not address the primary reason for the use of a TCA such as amitriptyline (Elavil) in IBS. B. A common response to TCAs is sedation; however, this medication is not given for this reason. C. TCAs do have anticholinergic side effects and can cause (not prevent) constipation. Clients with IBS can have constipation or diarrhea. D. Evidence supports that TCAs can reduce abdominal pain, and this benefit is unrelated to whether or not the client is being treated for depression.
Question 4 of 5
The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
Question 5 of 5
The client is scheduled for an abdominal-perineal resection for cancer of the rectum. Which components should the nurse include in the client’s preoperative education? Select all that apply.
Correct Answer: A,C,D,E
Rationale: An abdominal-perineal resection removes the sigmoid colon, rectum, and anus. As a result the client will have a permanent colostomy. The enterostomal nurse will identify and mark an appropriate stoma location after considering the client’s skinfolds, clothing preferences, and the level of the colostomy. The bowel is cleansed preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Antibiotics are prescribed to be given preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Postoperatively the client with an abdominal-perineal resection is at risk for sexual dysfunction and urinary incontinence as a result of nerve damage. This needs to be discussed with the client prior to surgery by the surgeon or a member of the surgical team.