GI NCLEX Questions (61-65)

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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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GI NCLEX Questions (1-5)


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GI NCLEX Questions (66-70)