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Ed's Oct.30-Nov.5

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1 Ed's Oct.30-Nov.5 on Tue Nov 08, 2011 12:35 am


Gastrointestinal NCLEX Questions

1. Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of:
a. 45 units/L
b. 100 units/L
c. 300 units/L
d. 500 units/L

2. A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse would offer which full liquid item to the client?
a. Tea
b. Gelatin
c. Custard
d. Popsicle

3. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of:
a. Pork
b. Milk
c. Chicken
d. Broccoli

4. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take?
a. Hold the feeding
b. Reinstill the amount and continue with administering the feeding
c. Elevate the client’s head at least 45 degrees and administer the feeding
d. Discard the residual amount and proceed with administering the feeding

5. A nurse is inserting a nasogastric
tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action?
a. Quickly insert the tube
b. Notify the physician immediately
c. Remove the tube and reinsert when the respiratory distress subsides
d. Pull back on the tube and wait until the respiratory distress subsides

6. Nurse Ryan is assessing for correct placement of a nosogartric tube. The nurse aspirates the stomach contents and check the contents for pH. The nurse verifies correct tube placement if which pH value is noted?
a. 3.5
b. 7.0
c. 7.35
d. 7.5

7. A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube?
a. Exhale
b. Inhale and exhale quickly
c. Take and hold a deep breath
d. Perform a Valsalva maneuver

8. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would:
a. Position the client supine to assist in medication absorption
b. Aspirate the nasogastric tube after medication administration to maintain patency
c. Clamp the nasogastric tube for 30 minutes following administration of the medication
d. Change the suction setting to low intermittent suction for 30 minutes after medication administration

9. A nurse is preparing to care for a female client with esophageal varices who has just has a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times?
a. An obturator
b. Kelly clamp
c. An irrigation set
d. A pair of scissors

10. Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D

11. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis?
a. Elevated hemoglobin level
b. Elevated serum bilirubin level
c. Elevated blood urea nitrogen level
d. Decreased erythrocycle sedimentation rate

12. The nurse is reviewing the physician’s orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the client’s chart?
a. NPO status
b. Nasogastric tube inserted
c. Morphine sulfate for pain
d. An anticholinergic medication

13. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test?
a. Fast for 8 hours before the test
b. Eat a regular supper and breakfast
c. Continue to take all oral medications as scheduled
d. Monitor own bowel movement pattern for constipation

14. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next?
a. Palpates the abdomen for size
b. Palpates the liver at the right rib margin
c. Listens to bowel sounds in all for quadrants
d. Percusses the right lower abdominal quadrant

15. Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate?
a. Start an IV infusion
b. Administer an enema
c. Cancel the diagnostic test
d. Explain that diarrhea is expected

Answers and Rationales

1. Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.
2. Answer C. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options A, B, and D are clear liquids.
3. Answer A. The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid
4. Answer A. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents are abnormal in color or characteristics.
5. Answer D. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.
6. Answer A. If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH.
7. Answer C. When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull.
8. Answer C. If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration.
9. Answer C. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client’s bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.
10. Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.
11. Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
12. Answer C. Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis.
13. Answer A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician
instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.
14. Answer C. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.
15. Answer D. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions.

From: NCLEX - Review

Signs and symptoms of IICP

1. LOC-Confusion, restlessness and letargy.

2. Pupillary dysfunction- Sluggish response to light.

3. Oculomotor dysfunction- Inability to move eyes upward.

4. Visual Abnormalities- Blurred vision.

5. Projectile Vomiting w/out nausea.

Positions Contraindicated w/ IICP

1. Prone position

2. Trandelenburg

3. Head turned to side, away from midline.

Rolling Eyes

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