NCLEX-PN
NCLEX Gastrointestinal Questions
Extract:
Question 1 of 5
Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis?
Correct Answer: D
Rationale: Loud, rushing bowel sounds are expected in gastroenteritis due to increased peristalsis from irritation. Decreased sounds, hard abdomen, or melena suggest other conditions.
Question 2 of 5
The client with a diagnosis of rule-out colon cancer is two (2) hours post-sigmoidoscopy procedure. Which assessment data warrant immediate intervention by the nurse?
Correct Answer: D
Rationale: Low BP (96/60) and tachycardia (pulse 108) suggest hypovolemia or bleeding post-sigmoidoscopy, requiring immediate intervention. Hyperactive bowel sounds, eating, and sleepiness are less urgent.
Question 3 of 5
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
Correct Answer: B
Rationale: Sudden resolution of abdominal pain may indicate perforation (e.g., appendicitis), a life-threatening emergency requiring immediate assessment. Urinary retention, absent bowel sounds, and discharge are less urgent.
Question 4 of 5
The client is admitted to a medical unit. The client’s medication list includes rifaximin, lactulose, and propranolol. Which assessment should be the nurse’s priority based on the client’s medication list?
Correct Answer: D
Rationale: A. Antibiotics and acid-reducing medications are expected with the treatment of PUD, but propranolol (Inderal) would not be expected. Although these medications may cue the nurse to further explore a history of PUD, this is not the most likely conclusion. B. There is no indication that the client has abdominal pain, and there isn’t an analgesic on the medication list. C. There is no indication that the client has an infectious condition necessitating airborne precautions. D. All medications listed are used to treat liver cirrhosis and its complications of portal hypertension and hepatic encephalopathy. The antibiotic rifaximin (Xifaxan) and the laxative lactulose (Cephulac) are used for treating hepatic encephalopathy. Thus, assessing the client’s neurological status and measuring abdominal girth are most important.
Question 5 of 5
The nurse is reviewing the health history of the client receiving treatment for hemorrhoids. Which information, related to the development of hemorrhoids, should the nurse expect to find in the client’s medical history?
Correct Answer: B, E
Rationale: Clients who are thin (BMI = 18) would have a decreased risk of hemorrhoid development. Obesity is a risk factor for hemorrhoid development. B. Prolonged constipation is a risk factor for development of hemorrhoids. C. Since pregnancy is a common cause of constipation, nulliparous women would have a decreased risk of hemorrhoid development. D. Sedentary rather than active occupations have an increased risk of hemorrhoid development. E. Iron supplements can lead to constipation and straining, which can precipitate hemorrhoid development.