Gastrointestinal NCLEX RN Questions Related

The nurse is caring for a 26-year-old patient who cannot meet their nutritional needs by mouth. The interdisciplinary team decided inserting an NG tube for enteral feedings would be best. After inserting the tube, the nurse knows which of the following is the most accurate way to verify the placement of the tube?

• A. Aspiration of stomach contents
• B. pH verification of the aspirate
• C. Injecting air into the tube and then auscultating the left upper quadrant (LUQ)
• D. Visualization on an X-ray

The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 6 of 6
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.

Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
1030: Client receiving LR at 150 mL/hr, calcium replacement completed. Urine output over the last 4 hours is 80 mL of dark amber urine. The client reports increased thirst. The abdomen continues to be distended with diminished bowel sounds. He reports that nausea has improved after receiving PRN medication. Increased edema noted in the lower extremities.

Orders
0630
• Ondansetron 4mg IV q6h PRN
• Calcium gluconate 2g IV over 5-10 minutes
• Lactated Ringer’s solution continuous infusion IV rate of 150mL/hr

The nurse knows that the client's condition is improving when they report a reduction in [condition].

• A. Urine output
• B. Pain
• C. Muscle strength
• D. None of the above

The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has

• A. An increase in oral temperature from 97.8°F (36.6°C) to 98.6°F (37°C).
• B. Rising aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels.
• C. A moderate amount of serosanguinous drainage to the incision.
• D. Nausea following the administration of oral pain medication.

The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply.

• A. Empties the pouch when it is one-third to one-half full.
• B. Washes the surrounding skin with moisturizing soap.
• C. Indicates that the reddish appearance of the stoma as normal.
• D. Applies sterile gloves prior to changing the device.
• E. Applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.

The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.

Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air

Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia

Which assessment findings require follow-up? Select all that apply.

• A. Jaundice
• B. Labored breathing
• C. Hypoactive bowel sounds
• D. Respiratory rate
• E. Oral temperature
• F. Yellow sclera