NCLEX Questions Gastrointestinal System
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Question 1 of 5.
The client had Billroth II surgery 24 hours ago. The client's son approaches the nurse in the hallway and asks for information regarding his father's condition. The wife is listed as the designated contact person. Which nurse response is best?
A. “What has the surgeon told you about your father's condition?â€
B. “Let's both go into your father's room and ask him how he feels.â€
C. “Let's go to a more private place to discuss your father's condition.â€
D. “Let's review your father's medical record information together.â€
Explanation: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client's room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.
Question 2 of 5.
The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Explanation: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.
Question 3 of 5.
Which statement made by the client indicates to the nurse the client may be experiencing GERD?
A. My chest hurts when I walk up the stairs in my home.
B. I take antacid tablets with me wherever I go.
C. My spouse tells me I snore very loudly at night.
D. I drink six (6) to seven (7) soft drinks every day.
Explanation: Frequent use of antacids suggests ongoing heartburn or reflux symptoms, a hallmark of GERD. Chest pain with exertion is more suggestive of cardiac issues, snoring may indicate sleep apnea, and soft drink consumption is a risk factor but not a direct symptom.
Question 4 of 5.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
A. Notify the health-care provider (HCP).
B. Assess the client for muscle weakness.
C. Request telemetry for the client.
D. Prepare to administer potassium IV.
Explanation: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
Question 5 of 5.
The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
A. My stoma should be pink and moist.
B. I will irrigate my ileostomy every morning.
C. If I get a red, bumpy, itchy rash I will call my HCP.
D. I will change my pouch if it starts leaking.
Explanation: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.
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