NCLEX 80 Q & A with rationals

Topics

• Liver Failure
• Liver Disorders
• Ostomy Care

Guidelines

• Read each question carefully and choose the best answer.
• You are given one minute per question. Spend your time wisely!
• Answers and rationales are given below. Be sure to read them.
• If you need more clarifications, please direct them to the comments section.

Questions and Answers

1. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure because of which change that is associated with the liver failure?

1. Hypoalbuminemia
2. Increased capillary permeability
3. Abnormal peripheral vasodilation
4. Excess rennin release from the kidneys

2. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

1. Pale, pink and moist
2. Red and moist
3. Dark or purple colored
4. Dry and black

3. You’re caring for a patient with a sigmoid colostomy. The stool from this colostomy is:

1. Formed
2. Semisolid
3. Semiliquid
4. Watery

4. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?

1. Peas
2. Cabbage
3. Broccoli
4. Yogurt

5. You have to teach ostomy self care to a patient with a colostomy. You tell the patient to measure and cut the wafer:

1. To the exact size of the stoma.
2. About 1/16” larger than the stoma.
3. About 1/8” larger than the stoma.
4. About 1/4″ larger than the stoma.

6. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?

1. Observation, percussion, palpation, auscultation
2. Observation, auscultation, percussion, palpation
3. Percussion, palpation, auscultation, observation
4. Palpation, percussion, observation, auscultation

7. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

1. A reservoir is created that exits through the abdominal wall.
2. A second surgery is required 12 months after the first surgery.
3. A permanent ileostomy is created.
4. The surgery occurs in two stages.

8. You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

1. 100 ml
2. 500 ml
3. 1500 ml
4. 5000 ml

9. You’re preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guideline do you include in this plan?

1. There is no need to change eating habits.
2. Eat six small meals a day.
3. Eat the largest meal in the evening.
4. Restrict fluid intake.
Answers

10. Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, “I know that I have colon cancer, too.” Which response is most therapeutic?

1. “I know just how you feel.”
2. “You seem upset.”
3. “Oh, don’t worry about it, everything will be just fine.”
4. “Why do you think you have cancer?”

11. You’re caring for Beth who underwent a Billroth II procedure (surgical removal of the pylorus and duodenum) for treatment of a peptic ulcer. Which findings suggest that the patient is developing dumping syndrome, a complication associated with this procedure?

1. Flushed, dry skin.
2. Headache and bradycardia.
3. Dizziness and sweating.
4. Dyspnea and chest pain.

12. You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?

1. Omit fluids with meals.
2. Increase carbohydrate intake.
3. Decrease protein intake.
4. Decrease fat intake.

13. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of which symptom indicated that the paracentesis was effective?

1. Pruritus
2. Dyspnea
3. Jaundice
4. Peripheral Neuropathy

14. You’re caring for Jane, a 57 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Before her paracentesis, you instruct her to:

1. Empty her bladder.
2. Lie supine in bed.
3. Remain NPO for 4 hours.
4. Clean her bowels with an enema.

15. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

1. Irrigate the wound & organs with Betadine.
2. Cover the wound with a saline soaked sterile dressing.
3. Apply a dry sterile dressing & binder.
4. Push the organs back & cover with moist sterile dressings.

16. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic encephalopathy in her?

1. Asterixis
2. Chvostek’s sign
3. Trousseau’s sign
4. Hepatojugular reflex

17. You are developing a care plan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?

1. Administering a lactulose enema as ordered.
2. Encouraging a protein-rich diet.
3. Administering sedatives, as necessary.
4. Encouraging ambulation at least four times a day.

18. You have a patient with achalasia (incomplete muscle relaxtion of the GI tract, especially sphincter muscles). Which medications do you anticipate to administer?

1. Isosorbide dinitrate (Isordil)
2. Digoxin (Lanoxin)
3. Captopril (Capoten)
4. Propranolol (Inderal)

19. The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:

1. Swallow foods while leaning forward.
2. Omit fluids at mealtimes.
3. Eat meals sitting upright.
4. Avoid soft and semi soft foods.

20. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient?

1. Serum creatinine and BUN
2. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
3. Serum amylase and lipase
4. Cardiac enzymes

21. A patient with Crohn’s disease is admitted after 4 days of diarrhea. Which of the following urine specific gravity values do you expect to find in this patient?

1. 1.005
2. 1.011
3. 1.020
4. 1.030

22. Your goal is to minimize David’s risk of complications after a herniorrhaphy. You instruct the patient to:

1. Avoid the use of pain medication.
2. Cough and deep breathe Q2H.
3. Splint the incision if he can’t avoid sneezing or coughing.
4. Apply heat to scrotal swelling.

23. Janice is waiting for discharge instructions after her herniorrhaphy. Which of the following instructions do you include?

1. Eat a low-fiber diet.
2. Resume heavy lifting in 2 weeks.
3. Lose weight, if obese.
4. Resume sexual activity once discomfort is gone.

24. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you include?

1. “You’ll need to lie on your stomach during the test.”
2. “You’ll need to lie on your right side after the test.”
3. “During the biopsy you’ll be asked to exhale deeply and hold it.”
4. “The biopsy is performed under general anesthesia.”

25. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?

1. Dyspnea and reduced or absent breath sounds over the right lung
2. Tachycardia, hypotension, and cool, clammy skin
3. Fever, rebound tenderness, and abdominal rigidity
4. Redness, warmth, and drainage at the biopsy site

26. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse 96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube. Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?

1. “It empties the stomach of fluids and gas.”
2. “It prevents spasms at the sphincter of Oddi.”
3. “It prevents air from forming in the small intestine and large intestine.”
4. “It removes bile from the gallbladder.”

27. Jason, a 22 y.o. accident victim, requires an NG tube for feeding. What should you immediately do after inserting an NG tube for liquid enteral feedings?

1. Aspirate for gastric secretions with a syringe.
2. Begin feeding slowly to prevent cramping.
3. Get an X-ray of the tip of the tube within 24 hours.
4. Clamp off the tube until the feedings begin.

28. Stephanie, a 28 y.o. accident victim, requires TPN. The rationale for TPN is to provide:

1. Necessary fluids and electrolytes to the body.
2. Complete nutrition by the I.V. route.
3. Tube feedings for nutritional supplementation.
4. Dietary supplementation with liquid protein given between meals.

29. Type A chronic gastritis can be distinguished from type B by its ability to:

1. Cause atrophy of the parietal cells.
2. Affect only the antrum of the stomach.
3. Thin the lining of the stomach walls.
4. Decrease gastric secretions.

30. Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?

1. Restrict intake of high-carbohydrate foods.
2. Increase fluid intake with meals.
3. Increase fat intake.
4. Eat three regular meals a day.

31. Jerod is experiencing an acute episode of ulcerative colitis. Which is priority for this patient?

1. Replace lost fluid and sodium.
2. Monitor for increased serum glucose level from steroid therapy.
3. Restrict the dietary intake of foods high in potassium.
4. Note any change in the color and consistency of stools.

32. A 29 y.o. patient has an acute episode of ulcerative colitis. What diagnostic test confirms this diagnosis?

1. Barium Swallow.
2. Stool examination.
3. Gastric analysis.
4. Sigmoidoscopy.

33. Eleanor, a 62 y.o. woman with diverticulosis is your patient. Which interventions would you expect to include in her care?

1. Low-fiber diet and fluid restrictions.
2. Total parenteral nutrition and bed rest.
3. High-fiber diet and administration of psyllium.
4. Administration of analgesics and antacids.

34. Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:

1. Watery and frothy.
2. Bloody and mucous.
3. Firm and well-formed.
4. Alternating constipation and diarrhea.

35. Donald is a 61 y.o. man with diverticulitis. Diverticulitis is characterized by:

1. Periodic rectal hemorrhage.
2. Hypertension and tachycardia.
3. Vomiting and elevated temperature.
4. Crampy and lower left quadrant pain and low-grade fever.

36. Brenda, a 36 y.o. patient is on your floor with acute pancreatitis. Treatment for her includes:

1. Continuous peritoneal lavage.
2. Regular diet with increased fat.
3. Nutritional support with TPN.
4. Insertion of a T tube to drain the pancreas.

37. Glenda has cholelithiasis (gallstones). You expect her to complain of:

1. Pain in the right upper quadrant, radiating to the shoulder.
2. Pain in the right lower quadrant, with rebound tenderness.
3. Pain in the left upper quadrant, with shortness of breath.
4. Pain in the left lower quadrant, with mild cramping.

38. After an abdominal resection for colon cancer, Madeline returns to her room with a Jackson-Pratt drain in place. The purpose of the drain is to:

1. Irrigate the incision with a saline solution.
2. Prevent bacterial infection of the incision.
3. Measure the amount of fluid lost after surgery.
4. Prevent accumulation of drainage in the wound.

39. Anthony, a 60 y.o. patient, has just undergone a bowel resection with a colostomy. During the first 24 hours, which of the following observations about the stoma should you report to the doctor?

1. Pink color.
2. Light edema.
3. Small amount of oozing.
4. Trickles of bright red blood.

40. Your teaching Anthony how to use his new colostomy. How much skin should remain exposed between the stoma and the ring of the appliance?

1. 1/16”
2. 1/4″
3. 1/2”
4. 1”

41. Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?

1. Obtain daily weights.
2. Measure abdominal girth.
3. Keep strict intake and output.
4. Encourage her to increase fluids.

42. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient?

1. TPN
2. PPN
3. NG feeding
4. Oral liquid supplements

43. You’re patient is complaining of abdominal pain during assessment. What is your priority?

1. Auscultate to determine changes in bowel sounds.
2. Observe the contour of the abdomen.
3. Palpate the abdomen for a mass.
4. Percuss the abdomen to determine if fluid is present.

44. Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next?

1. Discontinue the procedure.
2. Lower the height of the enema container.
3. Complete the procedure as quickly as possible.
4. Continue administration of the enema as ordered without making any adjustments.

45. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

1. There is no skin breakdown.
2. Her appetite improves.
3. She loses more than 10 lbs.
4. Stools are less fatty and decreased in frequency.

46. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?

1. Calcium
2. Glucose
3. Magnesium
4. Potassium

47. Anna is 45 y.o. and has a bleeding ulcer. Despite multiple blood transfusions, her HGB is 7.5g/dl and HCT is 27%. Her doctor determines that surgical intervention is necessary and she undergoes partial gastrectomy. Postoperative nursing care includes:

1. Giving pain medication Q6H.
2. Flushing the NG tube with sterile water.
3. Positioning her in high Fowler’s position.
4. Keeping her NPO until the return of peristalsis.

48. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

1. Blanched stoma
2. Edematous stoma
3. Reddish-pink stoma
4. Brownish-black stoma

49. Sharon has cirrhosis of the liver and develops ascites. What intervention is necessary to decrease the excessive accumulation of serous fluid in her peritoneal cavity?

1. Restrict fluids
2. Encourage ambulation
3. Increase sodium in the diet
4. Give antacids as prescribed

50. Katrina is diagnosed with lactose intolerance. To avoid complications with lack of calcium in the diet, which food should be included in the diet?

1. Fruit
2. Whole grains
3. Milk and cheese products
4. Dark green, leafy vegetables

51. Nathaniel has severe pruritus due to having hepatitis B. What is the best intervention for his comfort?

1. Give tepid baths.
2. Avoid lotions and creams.
3. Use hot water to increase vasodilation.
4. Use cold water to decrease the itching.

52. Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He’s jaundiced and reports weakness. Which intervention will you include in his care?

1. Regular exercise.
2. A low-protein diet.
3. Allow patient to select his meals.
4. Rest period after small, frequent meals.

53. You’re discharging Nathaniel with hepatitis B. Which statement suggests understanding by the patient?

1. “Now I can never get hepatitis again.”
2. “I can safely give blood after 3 months.”
3. “I’ll never have a problem with my liver again, even if I drink alcohol.”
4. “My family knows that if I get tired and start vomiting, I may be getting sick again.”

54. Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,”If I lie still and avoid turning after the operation, I’ll avoid pain. Do you think this is a good idea?” What is the best response?

1. “You’ll need to turn from side to side every 2 hours.”
2. “It’s always a good idea to rest quietly after surgery.”
3. “The doctor will probably order you to lie flat for 24 hours.”
4. “Why don’t you decide about activity after you return from the recovery room?”

55. You’re caring for a 28 y.o. woman with hepatitis B. She’s concerned about the duration of her recovery. Which response isn’t appropriate?

1. Encourage her to not worry about the future.
2. Encourage her to express her feelings about the illness.
3. Discuss the effects of hepatitis B on future health problems.
4. Provide avenues for financial counseling if she expresses the need.

56. Elmer is scheduled for a proctoscopy and has an I.V. The doctor wrote an order for 5mg of I.V. diazepam(Valium). Which order is correct regarding diazepam?

1. Give diazepam in the I.V. port closest to the vein.
2. Mix diazepam with 50 ml of dextrose 5% in water and give over 15 minutes.
3. Give diazepam rapidly I.V. to prevent the bloodstream from diluting the drug mixture.
4. Question the order because I.V. administration of diazepam is contraindicated.

57. Annabelle is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

1. “At first, the stoma may bleed slightly when touched.”
2. “The stoma should appear dark and have a bluish hue.”
3. “A burning sensation under the stoma faceplate is normal.”
4. “The stoma should remain swollen away from the abdomen.”
Answers

58. A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?

1. Rapidly instill a stream of irrigating solution into the wound.
2. Apply a wet-to-dry dressing to the wound after the irrigation.
3. Moisten the area around the wound with normal saline solution after the irrigation.
4. Irrigate continuously until the solution becomes clear or all of the solution is used.

59. Hepatic encephalopathy develops when the blood level of which substance increases?

1. Ammonia
2. Amylase
3. Calcium
4. Potassium

60. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?

1. A suture kit.
2. Sterile water and a suture kit.
3. Sterile water and sterile dressings.
4. Sterile saline solution and sterile dressings.

61. Findings during an endoscopic exam include a cobblestone appearance of the colon in your patient. The findings are characteristic of which disorder?

1. Ulcer
2. Crohn’s disease
3. Chronic gastritis
4. Ulcerative colitis

62. What information is correct about stomach cancer?

1. Stomach pain is often a late symptom.
2. Surgery is often a successful treatment.
3. Chemotherapy and radiation are often successful treatments.
4. The patient can survive for an extended time with TPN.

63. Dark, tarry stools indicate bleeding in which location of the GI tract?

1. Upper colon.
2. Lower colon.
3. Upper GI tract.
4. Small intestine.

64. A patient has an acute upper GI hemorrhage. Your interventions include:

1. Treating hypovolemia.
2. Treating hypervolemia.
3. Controlling the bleeding source.
4. Treating shock and diagnosing the bleeding source.

65. You promote hemodynamic stability in a patient with upper GI bleeding by:

1. Encouraging oral fluid intake.
2. Monitoring central venous pressure.
3. Monitoring laboratory test results and vital signs.
4. Giving blood, electrolyte and fluid replacement.

66. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you he’s anxious. What should your initial step be in working with this patient?

1. Determine what the patient already knows about colostomies.
2. Show the patient some pictures of colostomies.
3. Arrange for someone who has a colostomy to visit the patient.
4. Provide the patient with written material about colostomy care.

67. Your patient, Christopher, has a diagnosis of ulcerative colitis and has severe abdominal pain aggravated by movement, rebound tenderness, fever, nausea, and decreased urine output. This may indicate which complication?

1. Fistula.
2. Bowel perforation.
3. Bowel obstruction.
4. Abscess.

68. A patient has a severe exacerbation of ulcerative colitis. Long-term medications will probably include:

1. Antacids.
2. Antibiotics.
3. Corticosteroids.
4. Histamine2-receptor blockers.

69. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient’s diet?

1. Meats and beans.
2. Butter and gravies.
3. Potatoes and pastas.
4. Cakes and pastries.

70. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

1. Notify the doctor immediately.
2. Stop the feeding, and clamp the NG tube.
3. Discard the 220ml, and clamp the NG tube.
4. Give a prescribed GI stimulant such as metoclopramide (Reglan).

71. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

1. Increase the I.V. infusion rate.
2. Use diversion activities.
3. Provide frequent mouth care.
4. Give ice chips every 15 minutes.

72. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

1. He has fresh, active upper GI bleeding.
2. He needs immediate saline gastric lavage.
3. His gastric bleeding occurred 2 hours earlier.
4. He needs a transfusion of packed RBC’s.

73. A 53 y.o. patient has undergone a partial gastrectomy for adenocarcinoma of the stomach. An NG tube is in place and is connected to low continuous suction. During the immediate postoperative period, you expect the gastric secretions to be which color?

1. Brown.
2. Clear.
3. Red.
4. Yellow.

74. Your patient has a retractable gastric peptic ulcer and has had a gastric vagotomy. Which factor increases as a result of vagotomy?

1. Peristalsis.
2. Gastric acidity.
3. Gastric motility.
4. Gastric pH.

75. Christina is receiving an enteral feeding that requires a concentration of 80 ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?

1. 60 ml.
2. 70 ml.
3. 80 ml.
4. 90 ml.

76. Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown?

1. Ileostomy.
2. Ascending colostomy.
3. Transverse colostomy.
4. Descending colostomy.

77. George has a T tube in place after gallbladder surgery. Before discharge, what information or instructions should be given regarding the T tube drainage?

1. “If there is any drainage, notify the surgeon immediately.”
2. “The drainage will decrease daily until the bile duct heals.”
3. “First, the drainage is dark green; then it becomes dark yellow.”
4. “If the drainage stops, milk the tube toward the puncture wound.”

78. Your patient Maria takes NSAIDS for her degenerative joint disease, has developed peptic ulcer disease. Which drug is useful in preventing NSAID-induced peptic ulcer disease?

1. Calcium carbonate (Tums)
2. Famotidine (Pepcid)
3. Misoprostol (Cytotec)
4. Sucralfate (Carafate)

Answers
79. The student nurse is participating in colorectal cancer-screening program. Which patient has the fewest risk factors for colon cancer?

1. Janice, a 45 y.o. with a 25-year history of ulcerative colitis
2. George, a 50 y.o. whose father died of colon cancer
3. Herman, a 60 y.o. who follows a low-fat, high-fiber diet
4. Sissy, a 72 y.o. with a history of breast cancer
Answers

80. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

1. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.
2. Obtain vital signs, call the doctor, and obtain emergency orders.
3. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees.
4. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.


Answers