NSG 4100 EXAM 1 NCLEX: ACTUAL QUESTIONS AND ANSWERS
LATEST UPDATED 2026/2027 (GRADED A+)
Correct 66
Incorrect 00
Your answers
1 of 66
Term
The nurse is providing dietary instructions to a client
hospitalized for pancreatitis. Which food should the nurse
instruct the client to avoid?
1. Chili
2. Bagel
3. Lentil soup
4. Watermelon
1
Rationale:For the first 12 hours after gastric surgery, the nasogastric tube
drainage may be dark brown to dark red. Later, the drainage should
change to a light yellowish-brown color. The presence of bile may
cause a green tinge.
The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted
24 hours postoperatively.
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2
Rationale:Knowing that caffeinated beverages, such as coffee, tea, and
soda, will worsen symptoms, such as pain, will direct you to select the
correct option.
Alcohol can precipitate an attack of pancreatitis and needs to be avoided.
The recommended diet is moderate carbohydrates, low fat, and moderate
protein. Frothy, fatty stools indicate that the replacement enzyme dose
needs to be increased.
1
Rationale:The client with pancreatitis needs to avoid alcohol, coffee
and tea, spicy foods, and heavy meals, which stimulate pancreatic
secretions, producing attacks of pancreatitis. The client is instructed
in the benefit of eating small, frequent meals that are high in
protein, low in fat, and moderate to high in carbohydrates.
2
Rationale:Asterixis is a flapping tremor of the hand that is an early sign
of hepatic encephalopathy. The exact cause of this disorder is not known,
but abnormal ammonia metabolism may be implicated. Increased serum
ammonia levels are thought to interfere with normal cerebral
metabolism. Tremors and drowsiness also would be noted.
Don't know?
2 of 66
Term
A client with cirrhosis complicated by ascites is
admitted to the hospital. The client reports a 10-lb
weight gain over the past 1½ weeks. The client has
edema of the feet and ankles, and his
abdomen is distended, taut, and shiny with striae.
Which client problem is most appropriate at this time?
1. Difficulty with sleeping
2. Risk for skin breakdown
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3. Difficulty with breathing
4. Excessive body fluid volume
4
Rationale:The client with weight gain who also has cirrhosis
complicated by ascites most often is retaining fluid. This is
especially true when the client has not demonstrated an
appreciable increase in food intake or when the weight gain is
massive in relation to the time frame given. Therefore, excessive
body fluid volume is the most appropriate problem. No data are
given to support difficulty with breathing, although in some clients
upward pressure on the diaphragm from ascites does impair
respiration. Risk for skin breakdown assumes a lower priority
because it is a risk rather than an actual problem. There are no
data in the question that indicate that the
client is having difficulty with sleep.
4
Rationale:Disequilibrium syndrome is characterized by headache, mental
confusion, decreasing level of consciousness, nausea, vomiting,
twitching, and possible seizure activity. Disequilibrium syndrome is
caused by rapid removal of solutes from the body during hemodialysis.
At the same time, the blood-brain barrier interferes with the efficient
removal of wastes from brain tissue. As a
result, water goes into cerebral cells because of the osmotic gradient,
causing increased intracranial pressure and onset of symptoms. The
syndrome most often
occurs in clients who are new to dialysis and is prevented by
dialyzing for shorter times or at reduced blood flow rates. Tachycardia
and fever are associated with infection. Generalized weakness is
associated with low blood
pressure and anemia. Restlessness and irritability are not associated with
disequilibrium syndrome.
2
Rationale:The pain of pancreatitis is aggravated by lying supine or
walking. This is because the pancreas is located retroperitoneally,
and the edema and
Distribution of this document is extra per
illegal year?
LATEST UPDATED 2026/2027 (GRADED A+)
Correct 66
Incorrect 00
Your answers
1 of 66
Term
The nurse is providing dietary instructions to a client
hospitalized for pancreatitis. Which food should the nurse
instruct the client to avoid?
1. Chili
2. Bagel
3. Lentil soup
4. Watermelon
1
Rationale:For the first 12 hours after gastric surgery, the nasogastric tube
drainage may be dark brown to dark red. Later, the drainage should
change to a light yellowish-brown color. The presence of bile may
cause a green tinge.
The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted
24 hours postoperatively.
, Stuvia.com - The Marketplace to Buy and Sell your Study
Material
2
Rationale:Knowing that caffeinated beverages, such as coffee, tea, and
soda, will worsen symptoms, such as pain, will direct you to select the
correct option.
Alcohol can precipitate an attack of pancreatitis and needs to be avoided.
The recommended diet is moderate carbohydrates, low fat, and moderate
protein. Frothy, fatty stools indicate that the replacement enzyme dose
needs to be increased.
1
Rationale:The client with pancreatitis needs to avoid alcohol, coffee
and tea, spicy foods, and heavy meals, which stimulate pancreatic
secretions, producing attacks of pancreatitis. The client is instructed
in the benefit of eating small, frequent meals that are high in
protein, low in fat, and moderate to high in carbohydrates.
2
Rationale:Asterixis is a flapping tremor of the hand that is an early sign
of hepatic encephalopathy. The exact cause of this disorder is not known,
but abnormal ammonia metabolism may be implicated. Increased serum
ammonia levels are thought to interfere with normal cerebral
metabolism. Tremors and drowsiness also would be noted.
Don't know?
2 of 66
Term
A client with cirrhosis complicated by ascites is
admitted to the hospital. The client reports a 10-lb
weight gain over the past 1½ weeks. The client has
edema of the feet and ankles, and his
abdomen is distended, taut, and shiny with striae.
Which client problem is most appropriate at this time?
1. Difficulty with sleeping
2. Risk for skin breakdown
Distribution of this document is extra per
illegal year?
,Distribution of this document is extra per
illegal year?
, Stuvia.com - The Marketplace to Buy and Sell your Study
Material
3. Difficulty with breathing
4. Excessive body fluid volume
4
Rationale:The client with weight gain who also has cirrhosis
complicated by ascites most often is retaining fluid. This is
especially true when the client has not demonstrated an
appreciable increase in food intake or when the weight gain is
massive in relation to the time frame given. Therefore, excessive
body fluid volume is the most appropriate problem. No data are
given to support difficulty with breathing, although in some clients
upward pressure on the diaphragm from ascites does impair
respiration. Risk for skin breakdown assumes a lower priority
because it is a risk rather than an actual problem. There are no
data in the question that indicate that the
client is having difficulty with sleep.
4
Rationale:Disequilibrium syndrome is characterized by headache, mental
confusion, decreasing level of consciousness, nausea, vomiting,
twitching, and possible seizure activity. Disequilibrium syndrome is
caused by rapid removal of solutes from the body during hemodialysis.
At the same time, the blood-brain barrier interferes with the efficient
removal of wastes from brain tissue. As a
result, water goes into cerebral cells because of the osmotic gradient,
causing increased intracranial pressure and onset of symptoms. The
syndrome most often
occurs in clients who are new to dialysis and is prevented by
dialyzing for shorter times or at reduced blood flow rates. Tachycardia
and fever are associated with infection. Generalized weakness is
associated with low blood
pressure and anemia. Restlessness and irritability are not associated with
disequilibrium syndrome.
2
Rationale:The pain of pancreatitis is aggravated by lying supine or
walking. This is because the pancreas is located retroperitoneally,
and the edema and
Distribution of this document is extra per
illegal year?
