NCLEX G1

The nurse is caring for a client with a nasogastric tube. Which observation is most reliable in determining that the tube is correctly placed? 1.The aspirate is dark green. 2.The pH of the aspirate is 5. 3.The aspirate is negative for guaiac. 4.The tube is inserted the length measured from the client's ear to nose and nose to xiphoid process.

2,4

The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse question? 1.Lorazepam (Ativan) 2.Furosemide (Lasix) 3.Omeprazole (Prilosec) 4.Acetaminophen (Tylenol)

3,4

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 1.Bowel sounds are absent. 2.The aspirate from the tube has a pH of 7.45. 3.The aspirate from the tube has a pH of 6.5. 4.The tube can be palpated to the right of the umbilicus.

4

Which statement by the spouse of a client with end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding the management of pain? 1."If constipation is a problem, increased fluids will help." 2."If the pain increases, I must let the doctor know immediately." 3."This opioid will cause very deep sleep, which is what my husband needs." 4."I should have my husband try the breathing exercises to help control pain."

4

After a liver biopsy, the nurse should place the client in which position? 1.Trendelenburg and on the left side 2.Prone with the head of the bed in a flat position 3.Supine with the head of the bed at a 30-degree angle 4.A right side-lying position with a small pillow or folded towel under the puncture site

4 A right side-lying position with a small pillow or folded towel under the puncture site. This is correct because this stops the bleeding from the surgical site.(pressure)

The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse should suspect that the client has which diagnosis? 1.Gastritis 2.Esophageal varices 3.Bowel obstruction 4.Small bowel tumor

2

The nurse is collecting data on a client admitted to the hospital with hepatitis. Which data indicate that the client may have liver damage? 1.Pruritus 2.Cool dry skin 3.Dark brown stools 4.Yellow, straw-colored urine

4

A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client? 1.Low fat 2.Low fiber 3.High fiber 4.High carbohydrate

1

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention should be appropriate? 1.Offer small, frequent meals. 2.Encourage foods low in calories. 3.Explain that high-fat diets are usually better tolerated. 4.Explain that the majority of calories needs to be consumed in the evening hours.

1

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom is associated with a hiatal hernia? 1.Dry cough 2.Left lower quadrant pain 3.Heartburn and regurgitation 4.Moderate right upper quadrant pain

3

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse tells the client to avoid which position that could aggravate the pain? 1.Sitting up 2.Lying flat 3.Leaning forward 4.Flexing the left leg

3

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 1.Lying recumbent after meals 2.Eating small, frequent, bland meals 3.Raising the head of the bed on 6-inch blocks 4.Taking histamine receptor antagonist medication, as prescribed

3

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. The LPN should reinforce instructing the client to perform which action? 1.Exhale. 2.Inhale and exhale quickly. 3.Take and hold a deep breath. 4.Perform Valsalva's maneuver.

3

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 1.Sweating and pallor 2.Dry skin and stomach pain 3.Bradycardia and indigestion 4.Double vision and chest pain

1

A nurse planning care for a client with hepatitis plans to meet the client's safety needs by performing which action? 1.Bathing the client with tepid water and mild soap only 2.Assessing and recording the client's weight twice daily 3.Monitoring red blood cell and white blood cell counts daily 4.Monitoring prothrombin and partial thromboplastin values

3

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1.Observe the digestion of formula. 2.Check fluid and electrolyte status. 3.Evaluate absorption of the last feeding. 4.Confirm proper nasogastric tube placement.

3

The nurse is caring for a client with acute pancreatitis and a history of alcoholism and is monitoring the client for complications. Which data should be indicative of paralytic ileus? 1.Inability to pass flatus 2.Loss of anal sphincter control 3.Severe, constant pain with rapid onset 4.Firm, nontender mass palpable at the lower right costal margin

3

The nurse is collecting admission data on the client with hepatitis. Which finding would be a direct result of this client's condition? 1.Diarrhea 2.Drowsiness 3.Blurred vision 4.Urinary frequency

3

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history is least likely associated with this disease? 1.History of alcohol abuse 2.History of tarry black stools 3.History of gastric pain 2 to 4 hours after meals 4.History of the use of acetaminophen (Tylenol) for pain and discomfort

3

Which infection control method should be the priority to include in the plan of care to prevent hepatitis B in a client considered to be at high risk for exposure? 1.Hepatitis B vaccine 2.Proper personal hygiene 3.Use of immune globulin 4.Correct hand-washing technique

4

The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Following deflation of the balloon, the nurse should monitor the client closely for which? 1.Hematemesis 2.Bloody diarrhea 3.Swelling of the abdomen 4.An elevated temperature and a rise in blood pressure

1

A client is admitted to the hospital with acute viral hepatitis. Which sign/symptom should the nurse expect to note based on this diagnosis? 1.Fatigue 2.Pale urine 3.Weight gain 4.Spider angiomas

1

A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, which action does the nurse encourage the client to take? 1.Select foods high in fat. 2.Increase intake of fluids. 3.Eat less often, preferably only three large meals daily. 4.Eat a large supper when anorexia is most likely not as severe.

1

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse monitors the client closely for which esophageal complication? 1.Varices 2.Necrosis 3.Rupture 4.Hemorrhage

1

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing? 1.Hepatitis A 2.Hepatitis B 3.Hepatitis C 4.Hepatitis D

1

The nurse is caring for a client suspected of having appendicitis. Which should the nurse anticipate will be prescribed for this client? 1.Full liquid diet 2.Clear liquid diet 3.Mechanical soft diet 4.No oral intake of liquids or food

1

A client is seen in the ambulatory care office for a routine examination. Which statement by the client would be important for the nurse to follow up? 1."I just lost a family member to gastrointestinal cancer." 2."It's been over 18 months since I last had my prostate checked." 3."I have had a hard time following a low-sodium diet like I know I should." 4."I avoid overly hot or spicy foods because they always give me heartburn."

2

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 1.Initiate a tube feeding. 2.Notify the health care provider. 3.Document the finding in the client's record. 4.Pull the tube out 6 cm, and secure the tube to the nose with tape.

2

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? 1.Diarrhea 2.Constipation 3.Bloody stools 4.Stool constantly oozing from the rectum

3

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1.Right side 2.Low-Fowler's position 3.High-Fowler's position 4.Supine, with the head flat

3 High-Fowler's position

The nurse has given the client with hepatitis instructions about post discharge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement? 1."I should avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I should resume a full activity level within 1 week." 4."I should take the prescribed amounts of vitamin K."

4

The nurse is checking a client for the correct placement of a nasogastric (NG) tube. The nurse aspirates the client's stomach contents and checks its pH level. Which pH value indicates the correct placement of the tube? 1. 3.5 2. 4.5 3. 6.0 4. 7.35

1 3.5 The most accurate ph value for the stomach is 3.5 since the deeper you go, the more acidic it is. Norm range 5.5 below

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. Which data noted in the record indicate poor absorption of dietary fats? 1.Steatorrhea 2.Bloody diarrhea 3.Electrolyte disturbances 4.Gastrointestinal reflux disease

1,2

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures are most likely to promote coping? Select all that apply. 1.Ask a member of the local ostomy club to visit with the client before discharge. 2.Ask the enterostomal nurse specialist to consult with the client before discharge. 3.Remind the client frequently that infection is a major complication of a colostomy. 4.Remind the client frequently that he will be responsible for caring for the colostomy at home. 5.Ask the client to begin doing one part of the ostomy care and increase tasks daily.

1,2 3,4,5

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to note? Select all that apply. 1.Administer antacids, as prescribed. 2.Encourage small, frequent, high-calorie feedings. 3.Encourage coughing and deep breathing. 4.Administer anticholinergics, as prescribed. 5.Maintain the client in a supine and flat position.

1,4

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1.Offer small sips of water frequently. 2.Encourage the client to suck on sour, hard candy. 3.Use lemon glycerin swabs to provide oral hygiene. 4.Use diluted mouthwash and water to rinse the mouth after brushing teeth.

1,4

A calcium supplement is prescribed for a client with hypoparathyroidism in the management of hypocalcemia. The client arrives at the clinic for a follow-up visit and complains of chronic constipation, and the nurse reinforces instructions to the client about measures to alleviate the constipation. Which comment by the client would indicate a need for further teaching? 1."I need to increase my daily fluid intake." 2."I need to increase my intake of high-fiber foods." 3."I need to increase my activity level as tolerated." 4."I need to add 0.5 ounce of mineral oil to my daily diet."

2

A client has asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed? 1.High-iron diet 2.High-fiber diet 3.Low-purine diet 4.Low-sodium diet

2

A client has undergone esophagogastroduodenoscopy (EGD). The nurse places highest priority on which action as part of the client's care plan? 1.Monitoring the temperature 2.Checking for return of a gag reflex 3.Giving warm gargles for a sore throat 4.Monitoring for complaints of heartburn

2

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. On review of the postoperative prescriptions, which should the nurse clarify? 1.Leg exercises 2.Early ambulation 3.Irrigating the nasogastric (NG) tube 4.Coughing and deep-breathing exercises

2

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 1.Vitamin A 2.Vitamin C 3. Vitamin E 4.Vitamin B12

2

The nurse is reviewing the health care provider's prescriptions written for a client admitted with acute pancreatitis. Which health care provider prescription should the nurse verify if noted in the client's chart? 1.Maintain NPO status. 2.Administer an anticholinergic medication. 3.Position the client supine and flat. 4.Prepare to insert a nasogastric tube.

2

A client is admitted to an acute care facility with complications of celiac disease. Which question should be helpful initially in obtaining information for the nursing care plan? 1."How long have you been diagnosed?" 2."What types of foods do you like to eat?" 3."What is your understanding of celiac disease?" 4."Have you eliminated whole wheat bread from your diet?"

4

A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the health care provider plans to insert a Miller-Abbott tube. When the nurse tries to explain the procedure, the client interrupts the nurse and states, "I don't want to hear about that. Just let the doctor do it." Based on the client's statement, which is the nurse's best action? 1.Leave the room. 2.Remain with the client and be silent. 3.Ask the client whether he would like another nurse to care for him. 4.Explain to the client that all clients have the right to know about medical procedures.

4

The nurse is assisting in planning stress management strategies for the client with irritable bowel syndrome. Which suggestion should the nurse give to the client? 1.Rest in bed as much as possible. 2.Limit exercise to reduce bowel stimulation. 3.Try to avoid every possible stressful situation. 4.Learn measures such as biofeedback or progressive relaxation.

4

The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client supports the diagnosis of gastric ulcer? 1."The pain doesn't usually come right after I eat." 2."The pain gets so bad that it wakes me up at night." 3."The pain that I get is located on the right side of my chest." 4."My pain comes shortly after I eat, maybe a half hour or so later."

4

The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse determines that the client understands the instructions given if the client states that which food item is acceptable to include in the diet? 1.Beef chili 2.Grilled steak 3.Mashed potatoes 4.Turkey and lettuce sandwich

4

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred? 1.Dark and bluish 2.Sunken and hidden 3.Narrowed and flattened 4.Protruding and swollen

4

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse plans to include which risk factor for colorectal cancer in the material? 1.Age of 20 years 2.High-fiber, low-fat diet 3.Distant relative with colorectal cancer 4.Personal history of ulcerative colitis or gastrointestinal (GI) polyps

4

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include in client teaching to help prevent dumping syndrome? 1.Ambulate after a meal. 2.Eat high-carbohydrate foods. 3.Limit the fluids taken with meals. 4.Sit in a high-Fowler's position during meals.

4