NCLEX-PN Test #9 2 — Questions and Answers
Question 1: A client is scheduled for a colonoscopy in the morning. Which client statement indicates understanding of the bowel preparation?
- "I can eat a regular dinner the evening before the procedure."
- "I should take my morning blood pressure medications with a full glass of water."
- "I should consume only clear liquids today and complete the prescribed bowel prep solution." (Correct answer)
- "I can drink milk and juice but should avoid solid foods."
Correct answer: "I should consume only clear liquids today and complete the prescribed bowel prep solution."
Bowel prep for colonoscopy requires a clear liquid diet and a complete bowel cleansing solution to evacuate the colon. Adequate prep is essential for visualization and to prevent complications. Milk is NOT a clear liquid. Most medications should be taken as scheduled with small sips of water unless the provider instructs otherwise.
Question 2: The PN is providing care for a client with a new colostomy. Which statement by the client indicates a need for additional teaching?
- "I should empty the pouch when it is one-third full."
- "I will need to irrigate my colostomy every day." (Correct answer)
- "I should inspect the stoma with each pouch change; it should be pink and moist."
- "I can gradually return to most of my normal dietary habits."
Correct answer: "I will need to irrigate my colostomy every day."
Daily irrigation is not required for all colostomy clients. Irrigation is typically used for sigmoid colostomies to establish regular, predictable elimination and is a choice, not a requirement. Ascending and transverse colostomies produce liquid stool and cannot be regulated by irrigation. The client's misunderstanding requires correction.
Question 3: A client with chronic liver disease and ascites requires a paracentesis. After the procedure, which complication should the nurse monitor for most closely?
- Hypernatremia
- Hypovolemic shock from fluid shift (Correct answer)
- Pulmonary embolism
- Hyperkalemia
Correct answer: Hypovolemic shock from fluid shift
Rapid removal of large volumes of ascitic fluid (large-volume paracentesis) can cause fluid to shift from the vascular compartment into the peritoneal space, leading to hypovolemic shock. Vital signs, urine output, and mental status must be monitored closely after the procedure. Albumin infusion is often given to maintain intravascular volume.
Question 4: A client is admitted with a GI bleed and hematemesis. Which finding indicates the client is developing hemorrhagic shock?
- Blood pressure 130/80, HR 72
- Blood pressure 88/58, HR 124, pale and diaphoretic (Correct answer)
- Hemoglobin 10.5 g/dL with stable vital signs
- Dark, tarry stools with no vital sign changes
Correct answer: Blood pressure 88/58, HR 124, pale and diaphoretic
Hemorrhagic shock is characterized by hypotension (BP < 90 systolic), compensatory tachycardia (HR > 100), pallor, and diaphoresis from decreased cardiac output and compensatory sympathetic activation. These are emergency findings requiring immediate IV access, fluid resuscitation, blood products, and urgent endoscopy.
Question 5: The nurse is teaching a client about a low-residue (low-fiber) diet following bowel surgery. Which food choice is appropriate?
- Whole wheat bread with seeds
- Raw broccoli and cauliflower
- White rice, well-cooked carrots, and lean chicken (Correct answer)
- Bran cereal with dried fruit
Correct answer: White rice, well-cooked carrots, and lean chicken
A low-residue diet minimizes the amount of stool produced to allow bowel rest and healing after surgery. Appropriate choices include white refined grains, well-cooked vegetables without skins/seeds, lean meats, and eggs. High-fiber foods, raw vegetables, whole grains, nuts, and seeds are excluded.
Question 6: A client with pancreatitis has a serum amylase of 450 U/L and lipase of 900 U/L. Which nursing intervention is the priority?
- Encourage a clear liquid diet to rest the pancreas
- Maintain NPO (nothing by mouth) status and provide IV fluid hydration (Correct answer)
- Administer oral pancreatic enzyme supplements
- Prepare the client for urgent ERCP
Correct answer: Maintain NPO (nothing by mouth) status and provide IV fluid hydration
In acute pancreatitis, the priority is NPO status to prevent pancreatic stimulation (CCK release from food triggers enzyme secretion) combined with IV fluid resuscitation to prevent hypovolemia from third-spacing. Pain management (IV opioids) and electrolyte monitoring are also essential components of care.
NCLEX-PN Test #9 2
A client is scheduled for a colonoscopy in the morning.
Which client statement indicates understanding of the bowel preparation?