Nursing Leadership NCLEX Questions (36-40)

Welcome to Nursing Leadership 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


36. A registered nurse is a preceptor for a new nursing graduate an is describing critical paths and variance analysis to the new nursing graduate. The registered nurse instructs the new nursing graduate that a variance analysis is performed on all clients:

a) continuously
b) daily during hospitalization
c) every third day of hospitalization
d) every other day of hospitalization

37. When a nurse manager makes a decisions regarding the management of the nursing unit without input from the staff, the type of leadership style that the nurse manager is demonstrating is:

a) autocratic
b) situational
c) democratic
d) laissez-faire

38. A charge nurse knows that drug and alcohol use by nurses is a reason for the increasing numbers of disciplinary cares by the Board of Nursing. The charge nurse understands that when dealing with a nurse with such an illness, it is most important to assess the impaired nurse to determine:

a) the magnitude of drug diversion over time
b) if falsification of clients records occurred
c) the types of illegal activities related to the abuse
d) the physiological impact of the illness on practice

39. A nurse manager is planning to implement a change in the method of the documentation system for the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The initial step in the process of change for the nurse manager is which of the following?

a) plan strategies to implement the change
b) set goals and priorities regarding the change process
c) identify the inefficiency that needs improvement or correction
d) identify potential solutions and strategies for the change process

40. A nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs assistant to place which items at the bedside?

a) a tracheostomy set and oxygen
b) suction apparatus and an airway
c) an endotracheal tube and an airway
d) an emergency cart and laryngoscope








Nursing Leadership NCLEX Questions
Answers and Rationale

36) A

- Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options B, C and D are incorrect.

37) A

- The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The situational leadership style utilizes a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.

38) D

- A nurse must be able to function at a level that does not affect the ability to provide safe, quality care. The highest priority is to determine how the illness affects the nurse's ability to practice. The other options will be addressed if an investigation is carried out.

39) C

- When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems, because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

40) B

- Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and following a seizure. Suction is helpful to prevent choking and cyanosis. Options A and C are incorrect because inserting an endotracheal tube or a tracheostomy is not done. It is not necessary to have an emergency cart (which contains a laryngoscope) at the bedside, but a cart should be available in the treatment room or on the nursing unit.


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

Nursing Leadership NCLEX Questions (1-5)


Or proceed to the next set of questions:

Nursing Leadership NCLEX Questions (41-45)

Read More

Nursing Leadership NCLEX Questions (31-35)

Welcome to Nursing Leadership 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


31. Based upon a request made by the client's spouse and children, a physician asks a nurse to discontinue the feeding tube in a client who is in chronic debilitated and comatose state. The nurse understands the legal basis for carrying out the order and first checks the client's record for documentation of:

a) a court approval to discontinue the treatment
b) approval by the institutional Ethics Committee
c) a written order by the physician to remove the tube
d) authorization by the family to discontinue the treatment

32. A nurse plans to carry out a multidisciplinary research project on the effects of immobility on client's stress levels. Of the following statements, which principle is most important when planning this project?

a)  any client has the right to refuse to participate in research studies
b) collaboration with other disciplines is essential to the successful practice of nursing
c) the cooperation of the physicians on staff must be ensured in order for the project to succeed
d) the corporate nurse executive should be consulted, because the project will take nursing time

33. A nurse manager has identified a problem on the nursing unit and holds unit meetings for all shifts. The nurse manager presents an analysis of the problem and proposals for actions to team members and invites the team members to comment and provide input. Which style of leadership is the nurse manager specifically employing?

a)  situational
b) laissez-faire
c) participative
d) authoritarian

34. A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem-solve situations, and does not prioritize nursing care. The charge nurse has the responsibility to:

a)  supervise the staff nurse more closely so that tasks are completed
b) ask other staff members to help the staff nurse get the work done
c) provide support and identify the underlying cause of the staff nurse's problem
d) report the staff nurse to the supervisor so that something is done to resolve the problem


35. A registered nurse is preceptor for a new nursing graduate and is observing the new nursing graduate organize the client assignment and daily tasks. The registered nurse intervenes if the new nursing graduate does which of the following?

a) provide time for unexpected tasks
b) lists the supplies needed for a task
c) prioritizes client needs and daily tasks
d) plans to document task completion at the end of the day





Nursing Leadership NCLEX Questions
Answers and Rationale

31) D

- The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally, the family makes decisions in collaboration with physicians, other health care workers, and other trusted advisors. Although a written order by the physician is necessary, the nurse first checks for documentation of the family's request. Unless special circumstances exist, a court order is not necessary. Although some health care agencies may require reviewing such requests via the Ethics Committee, this is not the nurse's first action.

32) A

- The proposed project is research and includes human subjects. Although options B, C, and D need to be considered, they are all secondary to the overriding principle of the legal and ethical practice of nursing that any client has the right to refuse to participate in research using human subjects.

33) C

- Participative leadership demonstrates an "in-between" style, neither authoritarian nor democratic style. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The autocratic style of leadership is task oriented and directive. The situational leadership style utilizes a style depending on the situation and events.

34) C

Option C empowers the charge nurse to assist the staff nurse while trying to identify and reduce the behaviors that make it difficult for the staff nurse to function. Options A, B, and D are punitive actions, shift the burden to other workers, and do not solve the problem.

35) D

- The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time management.



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

Nursing Leadership NCLEX Questions (1-5)


Or proceed to the next set of questions:

Nursing Leadership NCLEX Questions (36-40)

Read More

Nursing Questions about Leadership and Management (26-30)

Welcome to Nursing Questions about Leadership and Management. 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


26. A nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed practical nurse (LPN) is assigned to the client. The appropriate action for the nurse to take is to:

a) reassign  the LPN to the care of clients not receiving opioids
b) notify the physician that the client needs an increase in opioid dosage
c) review the client's medication administration record immediately and discuss the observations with the nursing supervisor
d) confront the LPN with the information about the client having pain control problems and ask if the LPN is using the opioids personally

27. A medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of oral pyridostigmine bromide (Mestinon) to a client with myasthenia gravis. Which observation by the medication nurse would indicate safe practice by the LPN?

a) asking the client to take sips of water
b) asking the client to lie down on his right side
c) asking the client to look up at the ceiling for  30 seconds
d) instructing the client to void before taking the medication

28. During orientation, a graduate nurse learns that the nursing model of practice implemented in the facility is a primary nursing approach. When the nurse attends report on the medical unit, the nurse will verify with the staff which of the following characteristics of primary nursing?

a)  critical paths are used when providing client care
b) the nurse manager assigns tasks to the staff members
c) a registered nurse (RN) leads nursing staff in providing care to a group of clients
d) a single RN is responsible for planning and providing individualized nursing care to clients

29. A clinical nurse manager conducts an inservice educational session for the staff nurses about case management. The clinical nurse manager determines that a review of the material needs to be done if a staff nurse stated that case management:

a)  manages client care by managing the client care environment
b) maximizes hospital revenues while providing for optimal client care
c) is designed to promote appropriate use of hospital personnel and material resources
d) represents a primary health prevention focus managed by a single case manager

30. A nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs a variance analysis. Which of the following would indicate the need for further action and analysis?

a)  a client is performing his own colostomy care
b) purulent drainage is noted from a postoperative wound incision
c) a 1-day postoperative client has a temperature of 98.8F
d) a client newly diagnosed with diabetes mellitus is preparing his own insulin for injection





Nursing Questions about Leadership and Management
Answers and Rationale

26) C

- In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. The client does not need an increase in opioids. To reassign the LPN to clients not receiving opioids ignores the issue. A confrontation is not the most advisable action because it could result in an argumentative situation.

27) A

- Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options B and C are not appropriate. Option B could result in aspiration and option C has no useful purpose. There is no specific reason for the client to void before taking this medication.

28) D

- Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal-directed, individualized client care. Option A identifies a component of case management. Option B identifies functional nursing. Option C identifies team nursing.

29) D

- Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal client care. It manages client care by managing the client care environment.

30) C 

- Variances are actual deviations or detours from the critical paths. Variances can be either positive or negative, or avoidable or unavoidable and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken. Option B is the only option that identifies the need for further action.




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

Nursing Questions about Leadership and Management (1-5)


Or proceed to the next set of questions:

Nursing Questions about Leadership and Management (31-35)

Read More

Nursing Questions about Leadership and Management (21-25)

Welcome to Nursing Questions about Leadership and Management. 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


21. A nursing student prepares a postoperative plan of care for a client scheduled for hypophysectomy. The registered nurse reviews the plan and informs the nursing student that the plan needs to be corrected if which of the following was noted?

a) obtain daily weights
b) administer mouth care
c) monitor intake and output
d) encourage coughing and deep breathing

22. A nurse manager is reviewing with the nursing staff the purposes for applying  wrist and ankle restraints (security devices) to a client. The nurse manager determines that further review is necessary when a nursing staff member states that an indication for the use of a restraint is to:

a) limit movement of a limb
b) keep the client in bed at night
c) prevent the violent client from injuring self and others
d) prevent the client from pulling out intravenous lines and catheters

23. A hospitalized client with a diagnosis of anorexia nervosa and in a state of starvation is in two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be inappropriate to assign to this two-bed room?

a)  a client with pneumonia
b) a client who can perform self-care
c) a client with a fractured leg that is casted
d) a client who is scheduled for a diagnostic test

24. A multidisciplinary health care team is planning care for a client with hyperparathyroidism. The nurse identifies which client outcome to the health care team?

a) describes how to take antacids
b) restricts fluids to 1000 ml per day
c) describes how to take antidiarrheal medications
d) walks down the hall for 15 minutes, three times a day

25. A clinic nurse wants to develop a diabetic teaching program. In order to meet the client's needs, the nurse must first:

a)  assess the client's functional abilities
b) ensure that insurance will pay for participation in the program
c) discuss the focus of the program with the multidisciplinary team
d) include everyone who comes into the clinic in the teaching sessions






Nursing Questions about Leadership and Management
Answers and Rationale

21) D

- Toothbrushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy. These activities interfere with the healing of the incision and can disrupt the graft. Options A, B, and C are appropriate postoperative interventions.

22) B

- Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. They are applied to prevent the client from injuring self or others; from pulling out intravenous lines, catheters, or tubes; or from removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment.

23) A

- The client in a state of starvation has a compromised immune system. Having a roommate with pneumonia would place the client at risk for infection. Options B, C, and D are appropriate roommates.

24) D

- Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted. Options A and C are not specifically associated with this disorder.

25) A

- Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore the nurse must first assess the clients and their needs in order to effectively plan the program. Options B, C, and D do not address the clients' needs.


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

Nursing Questions about Leadership and Management (1-5)


Or proceed to the next set of questions:

Nursing Questions about Leadership and Management (26-30)

Read More

Immune System Practice Test (46-50)

Welcome to Immune System Practice Test. 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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


46. A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client?

a)  consume foods and beverages that are high in glucose
b) plan large menus and cook meals in advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout the day

47. A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living?

a) provide supportive care with hygiene needs
b) provide meals and snacks with high-protein, high calorie, and high-nutritional value
c) provide small, frequent meals
d) offer low microbial foods

48. A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?

a) the test should be repeated in 6 months
b) this ensures that the client is not infected with the HIV virus
c) the client no longer needs to protect himself from sexual partners
d) the client probably has immunity to the acquired immunodeficiency virus

49. A client is diagnosed with late stage human immunodeficiency virus (HIV), and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to:

a) tell the client and family to stop smoking because it will predispose the client to respiratory infections
b) tell the client and family that raw or improperly washed foods can produce microbes
c) encourage the client and family to discuss their feelings about the disease
d) advise the client to avoid becoming pregnant because of the risk of transmission of the infection

50. A client is diagnosed  with human immunodeficiency virus (HIV) infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which:

a) immunosuppression occurs and is indicated by a T4 lymphocyte count of less than 200/mm3
b) bacterial infection occurs, causing weakness
c) fungal infection occurs, causing a rash and pruritus
d) protozoan infection occurs, causing a fever and nonproductive cough





Immune System Practice Test 
Answers and Rationale

46) D

- The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

47) A
- Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.

48) A

- A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options B, C, and D are incorrect.

49) C

- The priority psychosocial nursing intervention for the client and family is to encourage the client and family to discuss their feelings about the disease. Options A, B, and D identify physiological not psychosocial concerns.

50) A

- HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoal infection can occur, these occur as opportunistic infections as a result of the immunosuppression.


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

Immune System Practice Test (1-5)

Read More

GI NCLEX Questions (71-75)

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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


71. A client receiving parenteral nutrition (PN) complains of nausea, excessive thirst, and increased frequency of voiding. The nurse initially assesses which of the following client data?

a) rectal temperature
b) last serum potasium
c) capillary blood glucose
d) serum blood urea nitrogen and creatinine

72. The nurse provides dietary measures to a client with diverticulosis. The nurse encourages the client to eat foods that are:

a)  high in fat
b) low in fiber
c) high in fiber
d) low roughage

73. A client who undergoes a gastric resection is at risk for developing dumping syndrome. The nurse monitors the client for:

a)  dizziness
b) bradycardia
c) constipation
d) extreme thirst

74. The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is most important for the nurse to assess the client's:

a)  tolerance to pain
b) allergy to iodine or shellfish
c) history of nausea and vomiting
d) ability to lie still and hold the breath

75.  A client who has had an abdominal aortic aneurysm repair is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. The nurse should:

a) feed the client
b) call the physician immediately
c) remove the nasogastric (NG) tube
d) document the finding and continue to assess  for bowel sounds







GI NCLEX Questions 
Answers and Rationale

71) C

- The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the client's blood glucose level to verify these data. Clients receiving PN are at risk for hyperglycemia related to the increased glucose load of the solution. The other options would not provide any information that would correlate with the client's symptoms.

72) C

- Diverticulosis is managed by consumption of a high-fiber diet and prevention of constipation with bran and bulk laxatives. A diet high in fat should be avoided because high-fat foods tend to be low in fiber. A low-roughage diet is similar to a low-fiber diet.

73) A

- Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

74) D

- It is most important for the nurse to assess the client's ability to lie still and hold the breath for the procedure. This helps the physician avoid complications, such as puncturing the lung or other organs. Assessment of allergy to iodine or shellfish is unnecessary for this procedure, because no contrast dye is used. Knowledge of the history related to nausea and vomiting is generally a part of assessment of the gastrointestinal system but has no relationship to the procedure. The client's tolerance for pain is a useful item to know. However, the area will receive a local anesthetic.

75) D

- Bowel sounds may be absent for 3 to 4 days postoperative due to bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. There is no need to call the physician immediately at this time.


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

GI NCLEX Questions (1-5)

Read More

GI NCLEX Questions (66-70)

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 :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck.


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.



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

GI NCLEX Questions (1-5)


Or proceed to the next set of questions:

GI NCLEX Questions (71-75)

Read More