NCLEX Gastrointestinal Disorders
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Question 1 of 5.
The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client's ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
A. Pulse rate for the last 24 hours
B. Urine output for the last 24 hours
C. Weight over the last 3 days
D. Ability to move the lower extremities
E. Temperature readings for the last 24 hours
Explanation: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.
Question 2 of 5.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
A. Notify the surgeon immediately.
B. Instruct the client to splint the incision.
C. Assess the abdominal wound incision.
D. Administer pain medication intravenously.
Explanation: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.
Question 3 of 5.
The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse?
A. The bulb is round and has 40 mL of fluid.
B. The drainage tube is taped to the dressing.
C. The JP insertion site is pink and has no drainage.
D. The JP bulb has suction and is sunken in.
Explanation: A round JP bulb with 40 mL of fluid indicates loss of suction, risking fluid accumulation and infection, requiring immediate intervention. Taping, pink site, and suction are normal.
Question 4 of 5.
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
A. When was your last bowel movement?
B. Did you have a high-fat meal last night?
C. Can you describe the type of pain?
D. Have you been experiencing any gas?
Explanation: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
Question 5 of 5.
The female client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority?
A. Altered nutrition.
B. Low self-esteem.
C. Disturbed body image.
D. Altered sexuality.
Explanation: Altered nutrition is the priority due to severe underweight (BMI ~13.2), risking organ failure and death. Self-esteem, body image, and sexuality are psychosocial and secondary.
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