NCLEX Questions Gastrointestinal 56-60

NCLEX Questions Gastrointestinal

56. A nurse is monitoring a postoperative client after abdominal surgery for signs of complications. The nurse assesses the client for the presence of Homan's sign and determines that his sign is positive if which of the following is noted?


a) incisional pain
b) absent bowel sounds
c) pain with dorsiflexion of the foot
d) crackles on auscultation of the lungs


57. A nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks 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



58. An adult client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. Which action by the nurse is most appropriate after seeing the laboratory results?

a) report the abnormally low count
b) report the abnormally high count
c) place the client on bleeding precautions
d) place the normal report in the client's medical record

59. An adult client with cirrhosis has been following a diet with optimal amounts of protein because neither an excess or a deficiency of protein has been helpful. The nurse evaluates the client's status as being most satisfactory if the total protein level in which of the following values?

a) 0.4 g/dL
b) 3.7 g/dL
c) 6.4 g/dL
ad 9.8 g/dL

60. A 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




NCLEX QUESTIONS GASTROINTESTINAL:
ANSWERS AND RATIONALE

56) C

- to elicit Homan's sign, the nurse would dorsiflex the client's foot and assess the client for pain in the calf area. If pain is present, a positive Homan's sign is present, which is an indication of thrombophlebitis. Incisional pain is an expected occurrence after abdominal surgery. Absent bowel sounds may occur in the immediate postoperative period. Crackles on auscultation of the lungs may indicate a respiratory complication.

57) 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.

58) D

- A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse should place the report containing the normal laboratory value in the client’s medical record. A platelet count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

59) C

- The normal range for total serum protein level in the adult client is 6.0 to 8.0 g/dL. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. Options A and B identify low values, and option D identifies a high protein value.

60) 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.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Questions Gastrointestinal (1-5)


Or proceed to the next set of questions:

NCLEX Questions Gastrointestinal (61-65)