Gastrointestinal Nursing Gastrointestinal Nursing NCLEX-PNNCLEX-PN

The nurse has an order to remove The nurse has an order to remove a patient’s nasogastric tube. The a patient’s nasogastric tube. The correct nursing action related to correct nursing action related to this procedure would be tothis procedure would be to

1.1. Put on sterile gloves after untaping the tube Put on sterile gloves after untaping the tube from the patient’s face.from the patient’s face.

2.2. Instill 30 mL of normal saline before removing Instill 30 mL of normal saline before removing the tube.the tube.

3.3. Pull the tube out slowly and gently.Pull the tube out slowly and gently.

4.4. Pull the tube out quickly while keeping it Pull the tube out quickly while keeping it pinched.pinched.

The nurse has an order to remove The nurse has an order to remove a patient’s nasogastric tube. The a patient’s nasogastric tube. The correct nursing action related to correct nursing action related to this procedure would be tothis procedure would be to

1.1. Put on sterile gloves after untaping the tube Put on sterile gloves after untaping the tube from the patient’s face.from the patient’s face.

2.2. Instill 30 mL of normal saline before removing Instill 30 mL of normal saline before removing the tube.the tube.

3.3. Pull the tube out slowly and gently.Pull the tube out slowly and gently.

4.4. Pull the tube out quickly while keeping it Pull the tube out quickly while keeping it pinched.pinched.

A patient with a history of A patient with a history of pernicious anemia has been pernicious anemia has been admitted to a long-term care admitted to a long-term care facility. There are no orders facility. There are no orders written. The LPN would ask the written. The LPN would ask the charge nurse to question the charge nurse to question the physician about obtaining medical physician about obtaining medical orders fororders for1.1. Folic acidFolic acid

2.2. IronIron

3.3. Vitamin B6Vitamin B6

4.4. Vitamin B12Vitamin B12

A patient with a history of A patient with a history of pernicious anemia has been pernicious anemia has been admitted to a long-term care admitted to a long-term care facility. There are no orders facility. There are no orders written. The LPN would ask the written. The LPN would ask the charge nurse to question the charge nurse to question the physician about obtaining medical physician about obtaining medical orders fororders for1.1. Folic acidFolic acid

2.2. IronIron

3.3. Vitamin B6Vitamin B6

4.4. Vitamin B12Vitamin B12

The nurse knows there is a The nurse knows there is a need for further teaching when need for further teaching when the patient taking Coumadin the patient taking Coumadin sayssays1.1. ““I cannot eat food high in vitamin K, such as I cannot eat food high in vitamin K, such as

leafy vegetables.”leafy vegetables.”

2.2. ““I can take aspirin for my ‘aches and pains’.”I can take aspirin for my ‘aches and pains’.”

3.3. ““I need to have a prothrombin time before I I need to have a prothrombin time before I return to the doctor.”return to the doctor.”

4.4. ““I need to report any bleeding to the doctor.”I need to report any bleeding to the doctor.”

The nurse knows there is a The nurse knows there is a need for further teaching when need for further teaching when the patient taking Coumadin the patient taking Coumadin sayssays1.1. ““I cannot eat food high in vitamin K, such as I cannot eat food high in vitamin K, such as

leafy vegetables.”leafy vegetables.”

2.2. ““I can take aspirin for my ‘aches and pains’.”I can take aspirin for my ‘aches and pains’.”

3.3. ““I need to have a prothrombin time before I I need to have a prothrombin time before I return to the doctor.”return to the doctor.”

4.4. ““I need to report any bleeding to the doctor.”I need to report any bleeding to the doctor.”

A patient is started on ASA A patient is started on ASA therapy. She tells the nurse that therapy. She tells the nurse that she is having a great deal of she is having a great deal of gastrointestinal distress. The gastrointestinal distress. The therapeutic response would be therapeutic response would be toto1.1. Inform the charge nurse so the physician can Inform the charge nurse so the physician can

change to another drug.change to another drug.

2.2. Explain that this happens frequently and there is Explain that this happens frequently and there is nothing to be concerned about.nothing to be concerned about.

3.3. Ask the patient when she takes the drug during the Ask the patient when she takes the drug during the day.day.

4.4. Tell the patient to take an antacid with the drug.Tell the patient to take an antacid with the drug.

A patient is started on ASA A patient is started on ASA therapy. She tells the nurse that therapy. She tells the nurse that she is having a great deal of she is having a great deal of gastrointestinal distress. The gastrointestinal distress. The therapeutic response would be therapeutic response would be toto1.1. Inform the charge nurse so the physician can Inform the charge nurse so the physician can

change to another drug.change to another drug.

2.2. Explain that this happens frequently and there is Explain that this happens frequently and there is nothing to be concerned about.nothing to be concerned about.

3.3. Ask the patient when she takes the drug during the Ask the patient when she takes the drug during the day.day.

4.4. Tell the patient to take an antacid with the drug.Tell the patient to take an antacid with the drug.

A 53-year-old female patient has A 53-year-old female patient has returned to the unit following a returned to the unit following a laparoscopic cholecystectomy. laparoscopic cholecystectomy. She complains of right shoulder She complains of right shoulder pain. The nurse would explain to pain. The nurse would explain to the patient that this pain isthe patient that this pain is1.1. Common following this type of operationCommon following this type of operation2.2. Expected after general anesthesia.Expected after general anesthesia.3.3. Unusual and will be reported to the surgeon.Unusual and will be reported to the surgeon.4.4. Indicative of a need to use the incentive Indicative of a need to use the incentive

spirometer.spirometer.

A 53-year-old female patient has A 53-year-old female patient has returned to the unit following a returned to the unit following a laparoscopic cholecystectomy. laparoscopic cholecystectomy. She complains of right shoulder She complains of right shoulder pain. The nurse would explain to pain. The nurse would explain to the patient that this pain isthe patient that this pain is1.1. Common following this type of operationCommon following this type of operation2.2. Expected after general anesthesia.Expected after general anesthesia.3.3. Unusual and will be reported to the surgeon.Unusual and will be reported to the surgeon.4.4. Indicative of a need to use the incentive Indicative of a need to use the incentive

spirometer.spirometer.

A patient with a bile duct A patient with a bile duct obstruction is jaundiced. The obstruction is jaundiced. The priority intervention to control the priority intervention to control the itching associated with jaundice is itching associated with jaundice is toto

1.1. Be sure the patient’s nails are clean and Be sure the patient’s nails are clean and short.short.

2.2. Maintain the room temperature at 72’-75’ F.Maintain the room temperature at 72’-75’ F.

3.3. Provide tepid water for bathing.Provide tepid water for bathing.

4.4. Use alcohol for back rubs.Use alcohol for back rubs.

A patient with a bile duct A patient with a bile duct obstruction is jaundiced. The obstruction is jaundiced. The priority intervention to control the priority intervention to control the itching associated with jaundice is itching associated with jaundice is toto

1.1. Be sure the patient’s nails are clean and Be sure the patient’s nails are clean and short.short.

2.2. Maintain the room temperature at 72’-75’ F.Maintain the room temperature at 72’-75’ F.

3.3. Provide tepid water for bathing.Provide tepid water for bathing.

4.4. Use alcohol for back rubs.Use alcohol for back rubs.

When a patient is in liver When a patient is in liver failure, which of the following failure, which of the following behavioral changes is the most behavioral changes is the most important assessment to important assessment to report?report?

1.1. Shortness of breathShortness of breath

2.2. Lethargy.Lethargy.

3.3. Fatigue.Fatigue.

4.4. Nausea.Nausea.

When a patient is in liver When a patient is in liver failure, which of the following failure, which of the following behavioral changes is the most behavioral changes is the most important assessment to important assessment to report?report?

1.1. Shortness of breathShortness of breath

2.2. Lethargy.Lethargy.

3.3. Fatigue.Fatigue.

4.4. Nausea.Nausea.

A 55-year-old patient with severe A 55-year-old patient with severe epigastric pain due to acute epigastric pain due to acute pancreatitis has been admitted to pancreatitis has been admitted to the hospital. The patient’s activity the hospital. The patient’s activity at this time should beat this time should be

1.1. Ambulation as desired.Ambulation as desired.

2.2. Bedrest in supine position.Bedrest in supine position.

3.3. Up ad lib and right side-lying position Up ad lib and right side-lying position in bed.in bed.

4.4. Bedrest in Fowler’s position.Bedrest in Fowler’s position.

A 55-year-old patient with severe A 55-year-old patient with severe epigastric pain due to acute epigastric pain due to acute pancreatitis has been admitted to pancreatitis has been admitted to the hospital. The patient’s activity the hospital. The patient’s activity at this time should beat this time should be

1.1. Ambulation as desired.Ambulation as desired.

2.2. Bedrest in supine position.Bedrest in supine position.

3.3. Up ad lib and right side-lying position Up ad lib and right side-lying position in bed.in bed.

4.4. Bedrest in Fowler’s position.Bedrest in Fowler’s position.

A patient with a history of cholecystitis A patient with a history of cholecystitis is now being admitted to the hospital is now being admitted to the hospital for possible surgical intervention. The for possible surgical intervention. The orders include NPO, IV therapy, and orders include NPO, IV therapy, and bedrest. In addition to assessing for bedrest. In addition to assessing for nausea, vomiting, and anorexia, the nausea, vomiting, and anorexia, the nurse should observe for painnurse should observe for pain

1.1. In the right lower quadrant.In the right lower quadrant.2.2. After ingesting food.After ingesting food.3.3. Radiating to the left shoulder.Radiating to the left shoulder.4.4. In the right upper quadrant.In the right upper quadrant.

A patient with a history of cholecystitis A patient with a history of cholecystitis is now being admitted to the hospital is now being admitted to the hospital for possible surgical intervention. The for possible surgical intervention. The orders include NPO, IV therapy, and orders include NPO, IV therapy, and bedrest. In addition to assessing for bedrest. In addition to assessing for nausea, vomiting, and anorexia, the nausea, vomiting, and anorexia, the nurse should observe for painnurse should observe for pain

1.1. In the right lower quadrant.In the right lower quadrant.2.2. After ingesting food.After ingesting food.3.3. Radiating to the left shoulder.Radiating to the left shoulder.4.4. In the right upper quadrant.In the right upper quadrant.

A patient scheduled for A patient scheduled for colostomy surgery will have a colostomy surgery will have a preoperative diet ordered that preoperative diet ordered that will include.will include.1.1. Broiled chicken, baked potato, and Broiled chicken, baked potato, and

wheat bread.wheat bread.2.2. Ground hamburger, rice and salad.Ground hamburger, rice and salad.3.3. Broiled fish, rice, squash, and tea.Broiled fish, rice, squash, and tea.4.4. Steak, mashed potatoes, raw carrots, Steak, mashed potatoes, raw carrots,

and celery.and celery.

A patient scheduled for A patient scheduled for colostomy surgery will have a colostomy surgery will have a preoperative diet ordered that preoperative diet ordered that will include.will include.1.1. Broiled chicken, baked potato, and Broiled chicken, baked potato, and

wheat bread.wheat bread.2.2. Ground hamburger, rice and salad.Ground hamburger, rice and salad.3.3. Broiled fish, rice, squash, and tea.Broiled fish, rice, squash, and tea.4.4. Steak, mashed potatoes, raw carrots, Steak, mashed potatoes, raw carrots,

and celery.and celery.

Lactulose is ordered for a 68-Lactulose is ordered for a 68-year-old patient hospitalized year-old patient hospitalized with hepatic failure. The nurse with hepatic failure. The nurse knows that the primary action knows that the primary action of this drug is toof this drug is to

1.1. Prevent constipation.Prevent constipation.

2.2. Decrease the blood ammonia level.Decrease the blood ammonia level.

3.3. Increase intestinal peristalsis.Increase intestinal peristalsis.

4.4. Prevent portal hypertension.Prevent portal hypertension.

Lactulose is ordered for a 68-Lactulose is ordered for a 68-year-old patient hospitalized year-old patient hospitalized with hepatic failure. The nurse with hepatic failure. The nurse knows that the primary action knows that the primary action of this drug is toof this drug is to

1.1. Prevent constipation.Prevent constipation.

2.2. Decrease the blood ammonia level.Decrease the blood ammonia level.

3.3. Increase intestinal peristalsis.Increase intestinal peristalsis.

4.4. Prevent portal hypertension.Prevent portal hypertension.

A female patient has orders for A female patient has orders for an oral cholecystogram. Prior an oral cholecystogram. Prior to the test, the nursing to the test, the nursing intervention would be tointervention would be to

1.1. Provide a high-fat diet for dinner, then NPO.Provide a high-fat diet for dinner, then NPO.

2.2. Explain that diarrhea may result from the Explain that diarrhea may result from the dye tablets.dye tablets.

3.3. Administer the dye tablets following a Administer the dye tablets following a regular diet for dinner.regular diet for dinner.

4.4. Administer enemas until clear.Administer enemas until clear.

A female patient has orders for A female patient has orders for an oral cholecystogram. Prior an oral cholecystogram. Prior to the test, the nursing to the test, the nursing intervention would be tointervention would be to

1.1. Provide a high-fat diet for diner, then NPO.Provide a high-fat diet for diner, then NPO.

2.2. Explain that diarrhea may result from the Explain that diarrhea may result from the dye tablets.dye tablets.

3.3. Administer the dye tablets following a Administer the dye tablets following a regular diet for dinner.regular diet for dinner.

4.4. Administer enemas until clear.Administer enemas until clear.

When a patient has peptic When a patient has peptic ulcer disease, the nurse would ulcer disease, the nurse would expect a priority intervention expect a priority intervention to beto be

1.1. Assisting in inserting a Miller-Abbott tube.Assisting in inserting a Miller-Abbott tube.

2.2. Assisting in inserting an arterial pressure Assisting in inserting an arterial pressure line.line.

3.3. Inserting a nasogastric tube.Inserting a nasogastric tube.

4.4. Inserting an IV.Inserting an IV.

When a patient has peptic When a patient has peptic ulcer disease, the nurse would ulcer disease, the nurse would expect a priority intervention expect a priority intervention to beto be

1.1. Assisting in inserting a Miller-Abbott tube.Assisting in inserting a Miller-Abbott tube.

2.2. Assisting in inserting an arterial pressure Assisting in inserting an arterial pressure line.line.

3.3. Inserting a nasogastric tube.Inserting a nasogastric tube.

4.4. Inserting an IV.Inserting an IV.

The nurse is assigned to work with The nurse is assigned to work with a patient diagnosed as having a patient diagnosed as having pernicious anemia. In evaluating pernicious anemia. In evaluating the diet for the patient, the nurse the diet for the patient, the nurse would know the patient would know the patient understands dietary parameters understands dietary parameters when he chooses.when he chooses.1.1. Meat, milk, cheeseMeat, milk, cheese2.2. Whole grains, cereals.Whole grains, cereals.3.3. Fruits, green leafy vegetables.Fruits, green leafy vegetables.4.4. Organ meats, yellow vegetables.Organ meats, yellow vegetables.

The nurse is assigned to work with The nurse is assigned to work with a patient diagnosed as having a patient diagnosed as having pernicious anemia. In evaluating pernicious anemia. In evaluating the diet for the patient, the nurse the diet for the patient, the nurse would know the patient would know the patient understands dietary parameters understands dietary parameters when he chooses.when he chooses.1.1. Meat, milk, cheese.Meat, milk, cheese.2.2. Whole grains, cereals.Whole grains, cereals.3.3. Fruits, green leafy vegetables.Fruits, green leafy vegetables.4.4. Organ meats, yellow vegetables.Organ meats, yellow vegetables.

After removing the fecal After removing the fecal impaction, the patient impaction, the patient complains of feeling complains of feeling lightheaded and the pulse rate lightheaded and the pulse rate is 44. The priority intervention is 44. The priority intervention is tois to1.1. Monitor vital signs.Monitor vital signs.

2.2. Place in shock position.Place in shock position.

3.3. Call the physician.Call the physician.

4.4. Begin CPR.Begin CPR.

After removing the fecal After removing the fecal impaction, the patient impaction, the patient complains of feeling complains of feeling lightheaded and the pulse rate lightheaded and the pulse rate is 44. The priority intervention is 44. The priority intervention is tois to1.1. Monitor vital signs.Monitor vital signs.

2.2. Place in shock position.Place in shock position.

3.3. Call the physician.Call the physician.

4.4. Begin CPR.Begin CPR.

Which nursing action is the most Which nursing action is the most critical when caring for a patient critical when caring for a patient who is receiving continuous who is receiving continuous nasogastric tube feedings?nasogastric tube feedings?

1.1. Warming the feeding to room temperature.Warming the feeding to room temperature.

2.2. Maintain accurate records of intake and output.Maintain accurate records of intake and output.

3.3. Flushing the tube with water every 4 hours.Flushing the tube with water every 4 hours.

4.4. Keeping the patient in a semi-Fowler’s position.Keeping the patient in a semi-Fowler’s position.

Which nursing action is the most Which nursing action is the most critical when caring for a patient critical when caring for a patient who is receiving continuous who is receiving continuous nasogastric tube feedings?nasogastric tube feedings?

1.1. Warming the feeding to room temperature.Warming the feeding to room temperature.

2.2. Maintain accurate records of intake and output.Maintain accurate records of intake and output.

3.3. Flushing the tube with water every 4 hours.Flushing the tube with water every 4 hours.

4.4. Keeping the patient in a semi-Fowler’s position.Keeping the patient in a semi-Fowler’s position.

A patient has reported to the A patient has reported to the ambulatory surgical center for a hernia ambulatory surgical center for a hernia repair. While in the preoperative area, repair. While in the preoperative area, the patient tells the nurse he is very the patient tells the nurse he is very nervous about the surgery. The best nervous about the surgery. The best response by the nurse isresponse by the nurse is

1.1. ““What did the physician tell you she is planning to do?”What did the physician tell you she is planning to do?”2.2. ““Do you usually get nervous about new experiences?”Do you usually get nervous about new experiences?”3.3. ““Your physician is very competent and will help you Your physician is very competent and will help you

get better.”get better.”4.4. ““Tell me how you are feeling right now.”Tell me how you are feeling right now.”

A patient has reported to the A patient has reported to the ambulatory surgical center for a hernia ambulatory surgical center for a hernia repair. While in the preoperative area, repair. While in the preoperative area, the patient tells the nurse he is very the patient tells the nurse he is very nervous about the surgery. The best nervous about the surgery. The best response by the nurse isresponse by the nurse is

1.1. ““What did the physician tell you she is planning to do?”What did the physician tell you she is planning to do?”2.2. ““Do you usually get nervous about new experiences?”Do you usually get nervous about new experiences?”3.3. ““Your physician is very competent and will help you Your physician is very competent and will help you

get better.”get better.”4.4. ““Tell me how you are feeling right now.”Tell me how you are feeling right now.”

The nurse is teaching a patient The nurse is teaching a patient with a new colostomy how to with a new colostomy how to apply an appliance to a colostomy. apply an appliance to a colostomy. How much skin should remain How much skin should remain exposed between the stoma and exposed between the stoma and the ring of the appliance?the ring of the appliance?

1.1. 1/8 inch.1/8 inch.2.2. ½ inch.½ inch.3.3. ¾ inch.¾ inch.4.4. I inch.I inch.

The nurse is teaching a patient The nurse is teaching a patient with a new colostomy how to with a new colostomy how to apply an appliance to a colostomy. apply an appliance to a colostomy. How much skin should remain How much skin should remain exposed between the stoma and exposed between the stoma and the ring of the appliance?the ring of the appliance?

1.1. 1/8 inch.1/8 inch.2.2. ½ inch.½ inch.3.3. ¾ inch.¾ inch.4.4. I inch.I inch.

A patient is admitted with a A patient is admitted with a diagnosis of esophageal varices. diagnosis of esophageal varices. When collecting data, the nurse When collecting data, the nurse will expect to find which of the will expect to find which of the following conditions that following conditions that contributed to the diagnosis.contributed to the diagnosis.

1.1. Decreases prothrombin formation.Decreases prothrombin formation.

2.2. Decreased albumin formation by the liver.Decreased albumin formation by the liver.

3.3. Portal hypertension.Portal hypertension.

4.4. Increased central venous pressure.Increased central venous pressure.

A patient is admitted with a A patient is admitted with a diagnosis of esophageal varices. diagnosis of esophageal varices. When collecting data, the nurse When collecting data, the nurse will expect to find which of the will expect to find which of the following conditions that following conditions that contributed to the diagnosis.contributed to the diagnosis.

1.1. Decreases prothrombin formation.Decreases prothrombin formation.

2.2. Decreased albumin formation by the liver.Decreased albumin formation by the liver.

3.3. Portal hypertension.Portal hypertension.

4.4. Increased central venous pressure.Increased central venous pressure.

One of the major goals of One of the major goals of therapy for a patient with therapy for a patient with peptic ulcer disease is topeptic ulcer disease is to1.1. Talk about the recent stressful situations, Talk about the recent stressful situations,

which may have contributed to the ulcer which may have contributed to the ulcer formation.formation.

2.2. Understand the pathogenesis of the Understand the pathogenesis of the ulcer.ulcer.

3.3. Accept that stress will negatively affect Accept that stress will negatively affect the condition.the condition.

4.4. Discover what food caused pain.Discover what food caused pain.

One of the major goals of One of the major goals of therapy for a patient with therapy for a patient with peptic ulcer disease is topeptic ulcer disease is to1.1. Talk about the recent stressful situations, Talk about the recent stressful situations,

which may have contributed to the ulcer which may have contributed to the ulcer formation.formation.

2.2. Understand the pathogenesis of the Understand the pathogenesis of the ulcer.ulcer.

3.3. Accept that stress will negatively affect Accept that stress will negatively affect the condition.the condition.

4.4. Discover what food caused pain.Discover what food caused pain.

Evaluating the effectiveness of Evaluating the effectiveness of preoperative teaching before preoperative teaching before colostomy surgery, the nurse colostomy surgery, the nurse expects that the patient will be expects that the patient will be able toable to

1.1. Describe how the procedure will be done.Describe how the procedure will be done.

2.2. Exhibit acceptance of the surgery.Exhibit acceptance of the surgery.

3.3. Explain the function of the colostomy.Explain the function of the colostomy.

4.4. Apply the colostomy bag correctly.Apply the colostomy bag correctly.

Evaluating the effectiveness of Evaluating the effectiveness of preoperative teaching before preoperative teaching before colostomy surgery, the nurse colostomy surgery, the nurse expects that the patient will be expects that the patient will be able toable to

1.1. Describe how the procedure will be done.Describe how the procedure will be done.

2.2. Exhibit acceptance of the surgery.Exhibit acceptance of the surgery.

3.3. Explain the function of the colostomy.Explain the function of the colostomy.

4.4. Apply the colostomy bag correctly.Apply the colostomy bag correctly.

For a patient with the diagnosis For a patient with the diagnosis of acute pancreatitis, the nurse of acute pancreatitis, the nurse would include which critical would include which critical component as part of the care component as part of the care plan?plan?

1.1. Testing for Homan’s sign.Testing for Homan’s sign.2.2. Measuring the abdominal girth.Measuring the abdominal girth.3.3. Performing a glucometer test.Performing a glucometer test.4.4. Straining the urine.Straining the urine.

For a patient with the diagnosis For a patient with the diagnosis of acute pancreatitis, the nurse of acute pancreatitis, the nurse would include which critical would include which critical component as part of the care component as part of the care plan?plan?

1.1. Testing for Homan’s sign.Testing for Homan’s sign.2.2. Measuring the abdominal girth.Measuring the abdominal girth.3.3. Performing a glucometer test.Performing a glucometer test.4.4. Straining the urine.Straining the urine.