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 (1-5)


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GI NCLEX Questions (71-75)