NCLEX Gastrointestinal

Extract:

Question 1 of 5

Which problem is most appropriate for the nurse to identify for the client with diarrhea?

Correct Answer: A

Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.

Question 2 of 5

The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?

A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour B. Initiate nasojejunal enteral feedings with a low-fat formula C. Imipenem-cilastatin 500 mg IV every 6 hours D. Up to chair for meals and ambulate four times daily E. Position left side-lying with head of bed elevated 30 degrees F. Insert a urinary catheter; monitor urine output every 2 hours

Correct Answer: A, B, C, F

Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.

Question 3 of 5

Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?

A. The client complains of clear to white sputum. B. The client has an episodic blister on the upper lip. C. The client complains of a nonhealing sore in the mouth. D. The client has bilateral ducts at the second molars.

Correct Answer: C

Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.

Question 4 of 5

The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?

A. The client's Bernstein esophageal test was positive. B. The client's abdominal x-ray shows a hiatal hernia. C. The client's WBC count is 14,000/mm3. D. The client's hemoglobin is 13.8 g/dL.

Correct Answer: C

Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.

Question 5 of 5

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication?

A. The client's pulse is 65 beats per minute. B. The client has shallow respirations. C. The client's bowel sounds are 20 per minute. D. The client uses a pillow to splint when coughing.

Correct Answer: B

Rationale: Shallow respirations suggest pain, as patients avoid deep breathing to minimize discomfort. Normal pulse, bowel sounds, and splinting are less direct indicators of pain.

NCLEX Gastrointestinal | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN