NCLEX - Gastrointestinal

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions should be included in the procedure? Select all that apply.

explain procedure to client ask patient to take deep breath and hold pull tube out remove device

A client that is postgastrectomy being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I may lose my job." Based on the client's statement, the nurse should determine that at this time, it is most appropriate to discuss which topic?

3

The nurse is caring for a client with a neurogenic bowel due to a lower motor neuron spinal cord injury below T12 resulting in flaccid functionality. Besides triggering or facilitating techniques for defecation, what are some of the strategies the nurse needs to address to reestablish defecation patterns? Select all that apply.

3,4,5

A client has had a partial gastrectomy and the nurse is reinforcing discharge instructions. The nurse should reinforce instructions to the client about the need for which supplements? Select all that apply.

2,4,5

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to digest food. The nurse determines that which processes are involved in the complete digestive process? Select all that apply.

2,4,5,6

A client diagnosis of a peptic ulcer scheduled for a vagotomy asks the nurse about the purpose of this procedure. The nurse should explain to the client that a vagotomy primarily serves which purpose?

3

A sexually active 20-year-old client has been diagnosed with viral hepatitis. Which statement made by the client would indicate a need for further teaching?

1

A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. The nurse should determine that which findings best validate this suspicion? Select all that apply.

1,2,3,5

The nurse who is reinforcing instructions to a client who has had a gastric resection should include which considerations? Select all that apply.

1,3

A client has undergone esophagogastroduodenoscopy (EGD). The nurse should place highest priority on which action as part of the client's care plan?

2

The client diagnosed with acute pancreatitis is experiencing severe pain from the disorder. The nurse should instruct the client to avoid which position that could aggravate the pain?

2

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

4

The nurse is providing care for a client with a nasogastric tube. Which observation is most appropriate in determining that the tube is correctly placed?

2

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid?

1

The nurse has been providing care for a client with a Sengstaken-Blakemore tube. While the tube is inflated the nurse should monitor for which priority sign/symptom?

1

The nurse analyzes the results of laboratory studies performed on a client with diagnosed peptic ulcer disease (PUD). Which laboratory value would most indicate a complication associated with the disease?

2

The nurse is assisting with admitting a client to the hospital for the treatment of diagnosed dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications being taking. The client denies taking prescription medications but states he has been taking some herbs given to him by a cousin. The nurse should alert the registered nurse when the client states he has been taking which herb?

2

The nurse is collecting admission data on the client with a diagnosis of hepatitis. Which finding should the nurse recognize to be a direct result of this client's condition?

2

The client in an emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.

1,2

A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is most likely a result of which condition that is part of the client's health history?

2

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse should take which immediate action?

1

A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse should instruct the client to avoid which behavior?

2

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

placement verified on x-ray

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

sweating and pallor

Which statement by the spouse of a client with diagnosed end-stage liver failure indicates the need for further teaching by the multidisciplinary team regarding management of the client's pain?

3

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which considerations concerning ongoing self-management should the nurse reinforce to the client? Select all that apply.

1,3

The nurse should include which instruction in a teaching plan for a client who has been diagnosed with peptic ulcer disease?

2

A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse should determine that which data would further support this diagnosis?

4

The nurse assigned to care for a client diagnosed with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?

4

The nurse is collecting data on a client with a diagnosis of peptic ulcer disease. Which history should the nurse determine is least likely associated with this disease?

4

A primary health care provider is about to perform a paracentesis on a client diagnosed with abdominal ascites. The nurse should assist the client to assume which position?

1

A client with a diagnosis of viral hepatitis has no appetite, and food makes the client nauseated. The nurse should conclude that which intervention is most appropriate?

1

The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse should anticipate a prescription to set the suction to which pressure?

3

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse should correctly select which tube from the unit storage area?

4

The nurse has assisted the primary health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse should assist the client into which position?

4

The nurse is preparing to administer a soapsuds enema to a client. Into which position should the nurse place the client to administer the enema? Refer to figure. View Figure

c

The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse explains to the client that it is important to continue to do which action after discharge?

1

A client receiving a high cleansing enema complains of pain and cramping. Which corrective action is most appropriate for the nurse to take?

4

The nurse should reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information?

4

A client with viral hepatitis states to the nurse, "I am so yellow." The nurse should best respond by taking which action?

1

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 data finding best indicates adequate location of the tube?

2

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client should take which action to monitor the effectiveness of treatment?

2

A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse should gather further information about the presence of which sign or symptom?

2

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include during client teaching to help prevent dumping syndrome?

limit the fluids taken with meals

A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item should be included when reinforcing instructions to the client about ongoing self-management?

1

Which infection control method should the nurse determine to 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

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 be prescribed? Select all that apply.

1,2,3

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 will most likely promote coping? Select all that apply.

1,2,5

The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The test results indicate a pH of 5. The nurse should determine this indicates which information?

2

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, the nurse should focus on which priority intervention?

2

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?

3

After the deflation of the balloon of a client's Sengstaken-Blakemore tube, the nurse should monitor the client closely for which priority esophageal complication?

4

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?

A

A client is admitted to the hospital with a diagnosis of acute viral hepatitis. Which sign/symptom should the nurse expect to observe based on this diagnosis?

1

The nurse is collecting data on a client admitted to the hospital with a diagnosis of hepatitis. The nurse should determine which data indicates the client may have liver damage?

1

The nurse notes that the medical record of a client diagnosed with cirrhosis states that the client has asterixis. To effectively verify this information the nurse should take which action?

1

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. The nurse should take which appropriate action?

1

The nurse should document that a client diagnosed with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action?

1

The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement?

3

The nurse is caring for a client with a Sengstaken-Blakemore tube. To effectively prevent ulceration and necrosis of oral and nasal mucosa, the nurse should plan to implement which action?

3

The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and should be immediately reported?

3

The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse should place the client in which position during and after the feedings?

3

The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which action should the nurse encourage the client to do?

3

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction to the client?

3

The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates a need for further teaching?

3

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce to the client? Select all that apply.

1,2,4

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart?

3

The nurse is working with a client diagnosed with anorexia nervosa. As the nurse plans care, which should be focused on as the primary problem?

3

The nurse should include which most appropriate information when reinforcing home care instructions for a client who has been diagnosed with peptic ulcer disease?

3

The nurse is caring for a client diagnosed with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed the nasogastric tube to be discontinued. To best determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check?

4

A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse should select which tube from the unit storage area?

4

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 most likely suspect that the client has which diagnosis?

4

The nurse is assisting in planning stress management strategies for the client diagnosed with irritable bowel syndrome. Which suggestion is most appropriate for the nurse to give to the client?

4

The nurse is caring for a client diagnosed with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?

4

The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse should plan care knowing that which could most result in a potential complication?

4

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?

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 should the nurse recognize as best supporting the diagnosis of gastric ulcer?

4

The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet?

4

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse should include which risk factor for colorectal cancer in the material?

4

The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse instructs the client about the importance of returning as scheduled to the health care clinic for which priority assessment?

4

The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer should avoid which intervention?

2

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

1

An acutely ill looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data should the nurse collect to assist in validating this suspicion? Select all that apply.

1,2,5

The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings should the nurse anticipate to be prescribed by the primary health care provider? Select all that apply.

1,5

The client arrives at an emergency department complaining of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the primary health care provider's prescriptions. Which prescription should the nurse most likely question if written on the primary health care provider's prescription form?

3

A client has a diagnosis of asymptomatic diverticular disease. Which type of diet should the nurse anticipate being prescribed?

2

A client is admitted to the hospital with a diagnosed bowel obstruction secondary to a recurrent diagnosed malignancy. The primary 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 action should the nurse determine is best?

2

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse should plan care, knowing that most likely, which problem will occur with this disorder?

2

Implemented treatment measures for a client with a diagnosis of bleeding esophageal varices have been unsuccessful. The primary health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse should prepare for insertion of this tube via which route?

2

The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which should the nurse suggest to the client to prevent swelling?

2

The nurse is reviewing the medication record of a client with a diagnosis of acute gastritis. Which medication noted on the client's record should the nurse most likely question?

2

A client that is postgastrectomy is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse should plan to monitor which data?

3

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse should most appropriately suggest which diet during the acute phase?

3

A generally healthy 63-year-old man is seen in the primary health care provider's office for a routine examination. Which statement made by the client is most important for the nurse to follow up on?

3

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed 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?

3

A calcium supplement is prescribed for a client diagnosed 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?

4

A client diagnosed peptic ulcer disease and scheduled for a pyloroplasty asks the nurse about the procedure. The nurse should base the response on which information?

4

A client diagnosed with chronic gastritis has been told that there is too little intrinsic factor being produced. The nurse should explain to the client that which therapy will be prescribed to treat the problem?

4

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?

4

A nurse organizing care for a client diagnosed with hepatitis plans to meet the client's safety needs by performing which action?

4

A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the primary health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and should ask the client to do which during tube removal?

4

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?

high fowler's position Rationale:Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?

limit bleeding from the biopsy site Rationale:After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. The liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not the purpose of the right side-lying position.

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?

vitamin B12 Rationale:Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 2, and 3 are incorrect.

A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse should suggest contacting the primary health care provider to request a prescription for which medication?

1

The client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse should gather which additional data from the client to support this diagnosis?

1

A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client?

2

A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion?

2

The client admitted to the hospital with a diagnosis of viral hepatitis is complaining of a loss of appetite. In order to provide adequate nutrition, which action should the nurse encourage the client to take?

2

A client is admitted to an acute care facility with complications of celiac disease. Which question asked by the nurse initially should be most helpful in obtaining information for the nursing care plan?

3

A client with a possible hiatal hernia complains of difficulty swallowing. Which other sign/symptom associated with a hiatal hernia should the nurse recognize?

3

A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement?

3

A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN should assist the client into which most appropriate position?

3

The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). Based on the procedure done, the nurse should plan to do which action first?

3

A client arrives at the emergency department complaining of severe abdominal pain and is placed on NPO status. During a quick assessment the nurse observes that the client has both Cullen's sign and Grey Turner's sign and pancreatitis is suspected. The nurse should assist to implement which action first?

4

The nurse is providing care for a client suspected of having appendicitis. Which priority intervention should the nurse anticipate will be prescribed for this client?

4

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?

4

The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of liver disease. Which medication prescription should the nurse most question?

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. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa?

4

A client is seen in the ambulatory care office for a routine examination. Which statement by the client should be most important for the nurse to follow up?

1

The nurse caring for a client diagnosed with acute pancreatitis and has a history of alcoholism is monitoring the client for complications. The nurse determines that which data collected is most likely indicative of paralytic ileus?

1

The nurse has been reinforcing dietary teaching for a client diagnosed with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?

1

The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescription?

1

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?

diarrhea

The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which statement made by the client indicates a need for further teaching?

1

The nurse is reviewing the health care record of a client with a diagnosis of chronic pancreatitis. The nurse should determine that which data noted in the record indicate poor absorption of dietary fats?

1

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations should the nurse include in the teaching session? Select all that apply.

1,3,4

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse determines to include which essential elements in the discharge teaching guide? Select all that apply.

2,3,4,5

A client admitted to the hospital diagnosed with severe jaundice is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. The nurse should determine which concern is most likely the reason for the client's reluctance to walk in the hall?

3

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should schedule the medication so that each dose is taken at which time?

3

The nurse gathers data from a client admitted to the hospital with a diagnosis of gastroesophageal reflux disease (GERD) scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse should determine that the client may be most at risk for which complication?

3

The nurse has a prescription to give 30 mL of an antacid through a nasogastric (NG) tube connected to wall suction. The nurse should do which best action to perform this procedure correctly?

3

The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement should the nurse make to the client for consideration?

2

The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement is most appropriate to be included in the teaching?

2

The nurse is interpreting the laboratory results of a client who has a history of diagnosed chronic ulcerative colitis. The nurse should determine that which result indicates a complication of ulcerative colitis?

1

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify?

irrigating the NG tube Rationale:In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the PHCP. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse should conclude which is the problem and what action should be taken?

4