Chapter 47 NCLEX style questions

The nurse is admitting a patient with a diagnosis of diverticulitis and assesses that the patient has a board like abdomen, no bowel sounds, an reports severe abdominal pain. What is the nurses first action? A. Start an IV with lactated ringer solution B. notify the health care provider C. administer a retention enema D. administer in opioid analgesic

B. notify the health care provider

The nurse is assigned to care for a patient two days after an appendectomy due to a ruptured appendix with resultant peritonitis. The nurse has just assisted the patient with ambulation to the bedside commode when the patient points to the surgical site and informs the nurse that "something gave way." What does the nurse suspect may have occurred? A. A drain may have become dislodged B. wound dehiscence has occurred C. Infection has developed D. the surgical wound has begun to bleed

B. wound dehiscence has occurred

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to discharge? A. Colonoscopy B. barium enema C. flexible sigmoidoscopy D. CT scan

A. Colonoscopy

A patient is having a diagnostic work up for reports of frequent diarrhea, right lower abdominal pain, and weight loss. The nurse is reviewing the results of the barium study and notes the presence of "string sign." What does the nurse recognize that this is significant of? A. Crohn's disease B. ulcerative colitis C. irritable bowel syndrome D. diverticulitis

A. Crohn's disease

The nurse is caring for an older adult patient experiencing fecal incontinence. When planning the care of this patient, what should the nurse designate as a priority goal? A. Maintaining skin integrity B. beginning a bowel program to establish continence C. instituting a diet high in fiber and increase fluid intake D. determining the need for surgical intervention to correct the problem

A. Maintaining skin integrity

The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurses notes? A. Loud bowel sounds B. Borborygmus C. Tenemus D. peristalsis

B. Borborygmus

The nurse is irrigating a colostomy when the patient says, "you will have to stop, I am cramping so badly." What is the priority action by the nurse? A. Inform the patient that it will only last a minute and continue with the procedure B. clamp the tubing and give the patient a rest period C. Stop the irrigation and remove the tube D. replace the fluid with cooler water since it is probably too warm

B. clamp the tubing and give the patient a rest period

The nurse is caring for a patient who has malabsorption syndrome with an undetermined cause. What procedure will the nurse assist with that is the best diagnostic test for this illness? A. Ultrasound B. endoscopy with mucosal biopsy C. stool specimen for ova and parasites D. pancreatic function tests

B. endoscopy with mucosal biopsy

The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing sign. Where should the nurse palpate for this indicator of acute appendicitis? A. Right lower quadrant B. left lower quadrant C. right upper quadrant D. left upper quadrant

B. left lower quadrant

A patient arrives in the emergency department reporting right lower abdominal pain that began 4 hours ago and is getting worse. The nurse assesses rebound tenderness at mcburney point. What does this assessment data indicate to the nurse A. Crohn's disease B. ulcerative colitis C. appendicitis D. diverticulitis

C. appendicitis

A patient is admitted to the hospital after not having had a bowel movement in several days. The nurse observes the patient is having small liquid stools, a grossly distended abdomen, and abdominal cramping. What complication can this patient develop related to this problem? A. Appendicitis B. rectal fissures C. bowel perforation D. diverticulitis

C. bowel perforation

The nurse is caring for a patient who has had an appendectomy. What is the best position for the nurse to maintain the patient in after the surgery? A. Prone B. Sims left lateral C. high Fowler D. supine with head of bed elevated 15 degrees

C. high Fowler

A patient is not having daily bowel movements and has begun taking a laxative for this problem. What should the nurse educate the patient about regarding laxative use? A. When taking the laxatives, plenty of fluids should be taken as well B. the laxatives should be taken no more than three times a week or laxative addiction will result C. laxatives should not be routinely taken due to destruction of nerve endings in the colon D. laxatives should never be the first response for the treatment of Constipation; Natural methods should be employed first

C. laxatives should not be routinely taken due to destruction of nerve endings in the colon

A patient is being seen in the clinic reporting painful hemorrhoids. The nurse assesses the patient and observes the hemorrhoids are prolapsed but able to be placed back in the rectum manually. the nurse documents the hemorrhoids as what degree? A. First degree B. second degree C. third degree D. 4th degree

C. third degree

A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify of trigger the symptoms? A. Document how much fluid is being taken to determine if the patient is over hydrating B. discontinue the use of any medication presently being taken to determine if medication is a trigger C. begin exercise regimen and biofeedback to determine if external stress is a trigger D. keep a one to two week symptom and food diary to identify food triggers

D. keep a one to two week symptom and food diary to identify food triggers