GI NCLEX Questions (66-70)

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66. A nurse is caring for a client with acute pancreatitis who has a history of alcoholism. The nurse closely monitors the client for paralytic ileus, knowing that which assessment data indicate this complication of pancreatitis?

a) inability to pass flatus
b) loss of anal sphincter control
c) severe, constant pain with rapid onset
d) firm, nontender mass palpable at the lower right costal margin

67. After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which of the following descriptions best describes this assessment finding?

a) waves of loud gurgles auscultated in all four quadrants
b) soft gurgling or clicking sounds auscultated in all four quadrants
c) low-pitched swishing sounds auscultated in one or two quadrants
d) very high-pitched loud rushes auscultated especially in one or two quadrants

68. The nurse is assessing a client with a Cantor tube. Which finding indicates correct placement of the tube?

a) a pH of aspirate less than 7.0
b) a pH of aspirate of 7.0 or greater
c) the auscultation of air when inserted into the abdomen
d) the presence of gastric contents when checking residuals

69. Then nurse is assisting the client with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which of the following entree items that could aggravate the client's condition?

a) tomato soup
b) fresh fruit plate
c) vegetable lasagna
d) ground beef patty

70. A client with a colostomy is complaining of gas building up in the colostomy bag. The nurse instructs the client that which of the following food items can be consumed to best prevent this problem?

a) yogurt
b) broccoli
c) cabbage
d) cauliflower






GI NCLEX Questions
Answers and Rationale

66) A

- An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 4 is the description of the physical finding of liver enlargement. The liver is usually enlarged in the client with cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus.

67) B

- Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard.

68) B

- The Cantor tube is an intestinal tube and is used for aspirating intestinal contents. For intestinal intubation the tube is threaded through the nose into the stomach and then through the pylorus, where peristaltic activity of the bowel carries it to the desired intestinal area. The nurse ensures intestinal placement by checking the pH of aspirate. A pH reading greater than 7 indicates intestinal contents; a reading less than 7 indicates gastric contents.

69) D

- Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, buttermilk, onions, peanut butter, and gelatin.

70) A

- Consumption of yogurt, crackers and toast can help to prevent gas. Gas-forming foods include broccoli, mushrooms, cauliflower, onions, peas, and cabbage. These should be avoided by the client with a colostomy until tolerance to them is determined.



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GI NCLEX Questions (61-65)

Welcome to GI NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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61. A client has had a Miller-Abbot tube in place for 24 hours. Which assessment finding indicates that the tube is located in the intestine?

a) the client is nauseous
b) bowel sounds are absent
c) aspirate from the tube has pH of 7
d) the abdominal radiograph report indicates that the end of the tube is above the pylorus

62. A client is resuming a diet after a Billroth II procedure. To minimize complications from eating, the nurse teaches the client to avoid doing which of the following?

a) lying down after eating
b) eating a diet high in protein
c) drinking liquids with meals
d) eating six small meals per day

63. A physician orders the deflation of the esophageal balloon of a Sengstaken-Blakemore tube in a client. The nurse prepares for the procedure, knowing that the deflation of the esophageal balloon places the client at risk for:

a) gastritis
b) increased ascites
c) esophageal necrosis
d) recurrent hemorrhage from the esophageal varices

64. The nurse is preparing to initiate bolus enteral feedings via nasogastric (NG) tube to a client. Which of the following actions represents safe practice by the nurse?

a) checks the volume of the residual after administering the bolus feeding
b) aspirates gastric contents prior to initiating the feeding and assures that pH is >9
c) elevates the head of the bed to 25 degrees and maintains for 30 minutes after instillation of feeding
d) measures the length of the tube from where it protrudes from the nose to the end and compares to previously documented measurements

65. A nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, and as the nurse starts to slowly advance the NGT with each swallow, the client begins ti gag. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

a) pulling the tube back slightly
b) instructing the client to breathe slowly
c) continuing to advance the tube to the desired distance
d) checking the back of the pharynx using a tongue blade and flashlight







GI NCLEX Questions
Answers and Rationale

61) C

- The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and to correct a bowel obstruction. The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Location of the tube can also be determined by radiographs.

62) C

- The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

63) D

- A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices.

64) D

- After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end; injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen; and aspirating the secretions and checking to see if the pH is between 1 and 5. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation. Residual should be assessed before administration of the next feeding.

65) C

- As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to reduce the gag response. The tube may be advanced after the client relaxes.


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Nursing Fundamentals Course (71-75)

Welcome to Nursing Fundamentals Course. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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71. The nurse inserts an indwelling urinary catheter into a male client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which should the nurse implement next?

a) inflate the balloon with water
b) insert the catheter 2.5 to 5 cm
c) measure the initial urine output
d) secure the catheter to the client

72. A nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

a) ask the client to obtain the specimen after breakfast
b) use a sterile plastic container for obtaining the specimen
c) provide tissues for expectoration and obtaining the specimen
d) ask the client to expectorate a small amount of sputum into the emesis basin

73. A client who is 40 years old has a severe mental impairment and is scheduled fro gallbladder surgery. Which should the nurse implement about the informed consent first to facilitate the scheduled surgery?

a) check for the identity of the client's legal guardian
b) inform the legal guardian about advanced directives
c) arrange fro the surgeon to provide informed consent
d) ensure that the legal guardian signed the informed consent

74. Which action does the nurse implement to obtain a urine specimen for a urinalysis from a female client with an indwelling urinary catheter?

a) detach the tubing of the drainage bag
b) use a sterile container for the specimen
c) cleanse the perineum from front to back
d) aspirate the urine from the drainage bag port

75. The nurse has given a subcutaneous injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse disposes of the used needle and syringe by:

a) breaking the needle before discarding it
b) recapping the needle and discarding the syringe in a disposal unit
c) placing the uncapped needle and syringe in a labeled cardboard box
d) placing the uncapped needle and syringe in labeled, rigid plastic container







Nursing Fundamentals Course
Answers and Rationale

71) B

- The catheter's balloon is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5 cm further after urine begins to flow in order to provide sufficient space to inflate the balloon. After the nurse secures the catheter to the client's leg, the nurse measures the initial urine output.

72) B

- Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques, because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. A first morning specimen is preferred because it represents overnight secretions of the tracheobronchial tree.

73) A

- The client is not competent to sign an informed consent, so the nurse verifies the identity of the client's legal guardian to fulfill part of the nurse's duty in informed consent. This helps avoid improperly signed documents and to direct the surgeon to the legal representatives of the client's interests. Most states require client notification of advanced directives at admission.

74) D

- A specimen for urinalysis does not need to be sterile; however, the system must remain sterile to reduce the risk of infection. Therefore, the nurse obtains the specimen using sterile technique and obtains a fresh specimen by aspirating urine from the drainage bag port after sanitizing the port and inserting a sterile needle. The nurse avoids breaking the integrity of the urinary collection system to prevent contamination. The nurse also avoids taking urine from the urinary drainage bag because the urine is less likely to reflect the current client status and because urine undergoes chemical changes and particulate matter settles over time. A sterile container is unnecessary for a urinalysis, and because the client has an indwelling catheter, perineal cleansing before obtaining a urine specimen is unnecessary.

75) D

- Standard precautions include specific guidelines for handling of needles. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container specific for this purpose. Needles should not be discarded in cardboard boxes, because these types of boxes are not impervious. Needles should never be left lying around after use.


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Nursing Fundamentals Course (1-5)

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Nursing Fundamentals Course (76-80)

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