NCLEX Gastrointestinal
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Question 1 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
Explanation: 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 2 of 5.
The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions?
A. I should not eat for at least one (1) day following this procedure.
B. I can lie down whenever I want after a meal. It won't make a difference.
C. The stomach contents won't bother my esophagus but will make me nauseous.
D. I should avoid orange juice and eating tomatoes until my esophagus heals.
Explanation: Avoiding acidic foods like orange juice and tomatoes reduces irritation to the esophagus, indicating understanding of dietary modifications for GERD. Not eating for a day is unnecessary, lying down after meals worsens reflux, and nausea is not the primary concern with GERD.
Question 3 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.
Explanation: 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 4 of 5.
Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis?
A. Twenty bloody stools a day.
B. Oral temperature of 102°F.
C. Hard, rigid abdomen.
D. Urinary stress incontinence.
Explanation: Ulcerative colitis commonly causes frequent bloody stools due to inflammation and ulceration of the colon mucosa. Fever may occur but is less specific, a hard abdomen suggests complications like perforation, and urinary incontinence is unrelated.
Question 5 of 5.
The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement?
A. Weigh the client daily and document in the client's chart.
B. Teach coping strategies such as dietary modifications.
C. Record the frequency, amount, and color of stools.
D. Monitor the client's oral fluid intake every shift.
Explanation: Recording stool frequency, amount, and color is critical in acute IBD exacerbation to assess disease activity and guide treatment. Weight and fluid monitoring are important but secondary, and teaching is less urgent during an acute phase.