Gastrointestinal NCLEX RN Questions
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Question 1 of 5.
Extract:The following scenario applies to the next 1 items The nurse in the emergency department is caring for a 19-year-old male client. Item 1 of 1 Nurses' Notes 0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia. Laboratory Results white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3] hemoglobin: 13.9 g/dL [14–18 g/dL] hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action To take
- A.Insert a peripheral venous access device (VAD)
- B. obtain a stool specimen for culture and sensitivity (C & S)
- C. prepare the client for surgery
- D. request an order for a clear liquid diet.
Potential Condition
- A.Peritonitis
- B. diverticulitis
- C. appendicitis
- D. gastroenteritis.
Parameter to Monitor
- A.Lung sounds
- B. pulse
- C. temperature
- D. hemoglobin and hematocrit.
Explanation: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (B). Inserting a VAD and preparing for surgery (A) are critical for anticipated appendectomy. Monitoring temperature and pulse (C) tracks infection and hemodynamic status.
Question 2 of 5.
The nurse is caring for a client receiving total parenteral nutrition (TPN), which was initiated twelve hours ago. The priority assessment for this client is which of the following?
A. Urine output
B. Oral temperature
C. Weight
D. Capillary blood glucose
Explanation: TPN contains high concentrations of glucose, which can lead to hyperglycemia, especially in the early stages of administration. Monitoring capillary blood glucose is critical to detect and manage this potential complication.
Question 3 of 5.
The nurse is conducting a telephone call following up with a client with a colostomy placed two weeks ago. Select the findings reported by the client that require follow-up by the nurse.
A. The client reports that he has no pain at the stoma.
B. He states that the stoma is red and moist.
C. He reports changing the appliance daily
D. He reports using moisturizing soap around the stoma.
E. The client notes that he empties the pouch when it is one-half to one-third full of stool.
F. The client stated that his stoma has been getting smaller in size since surgery.
Explanation: Changing the appliance daily (C) may indicate improper fit or skin irritation, requiring assessment. Using moisturizing soap (D) can interfere with appliance adhesion and cause skin issues, necessitating education on proper skin care.
Question 4 of 5.
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
A. Leukocytosis
B. Melena
C. Fever
D. Nausea and Vomiting
E. Anorexia
Explanation: Appendicitis commonly presents with leukocytosis (A) due to infection, fever (C) from inflammation, nausea and vomiting (D), and anorexia (E) due to gastrointestinal irritation. Melena (B) is not typically associated with appendicitis.
Question 5 of 5.
Extract:The following scenario applies to the next 1 items The nurse is caring for a client in the outpatient clinic Item 1 of 1 Nurses' Note 35-year-female arrives at the clinic for reported loss of appetite and nausea. The client reports that she is not eating as much because she experiences palpitations, sweating, and dizziness about thirty minutes after she eats. She reports that she has not been adherent to the prescribed diet and her symptoms worsen when she eats something sweet and drinks cola. Medical History • Morbid obesity (BMI 42) • Roux-en-Y procedure eight weeks ago
Complete the following sentence by choosing from the list of options. To prevent.........., the nurse should instruct the client ............. and ...........
A. Pernicious anemia
B. Dumping syndrome
C. Lie down after meals
D. Exercise after meals
E. Avoid drinking with meals
F. Eat food high in carbohydrates
G. Eat food high in vitamin B12
Explanation: Dumping syndrome (B) occurs post-Roux-en-Y due to rapid gastric emptying. Avoiding drinking with meals (E) slows digestion, reducing symptoms. Lying down after meals (C) can worsen symptoms and is not advised.
Related Questions
Which assessment findings require follow-up? Select all that apply.