NCLEX Gastrointestinal Disorders
Home / Nursing & Allied Health Certifications / NCLEX PN / Gastrointestinal
Question 1 of 5.
The nurse is preparing to admit the hospitalized client diagnosed with peritonitis. Which collaborative interventions should the nurse anticipate? Select all that apply.
A. Intravenous (IV) fluids
B. Oral or IV antibiotics
C. NPO (nothing per mouth) status
D. Analgesic medications
E. Positioning in a supine position
F. Nasogastric tube (NGT) to suction
Explanation: IV fluids are given to replace fluids shifting in the peritoneum and bowel from the inflammatory process. NPO status will rest the bowel. Analgesics are utilized for pain control. NG suction decompresses the stomach and intestine and rests the GI tract.
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.