NCLEX-PN
NCLEX Gastrointestinal Questions
Extract:
Question 1 of 5
While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
Question 2 of 5
The client with a newly created colostomy is concerned about having satisfying sexual relations. What should the nurse recommend?
Correct Answer: C
Rationale: Emptying the pouch before sexual activity is recommended to decrease the concern of pouch breakage or leakage; cleaning it will reduce odor.
Question 3 of 5
The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement?
Correct Answer: B
Rationale: Encouraging ventilation of feelings about body image is an independent nursing intervention addressing psychosocial needs post-colostomy. IV rate, opioids, and ambulation require orders or are less psychosocial.
Question 4 of 5
The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.
Question 5 of 5
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
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.