NSG 4100 EXAM 1 NCLEX QUESTION WITH 100% CORRECT AND
VERIFIED ANSWERS
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.
, 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
,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
inflammation will intensify the irritation of the posterior peritoneal wall with these
positions or movements. Positions such as sitting up, leaning forward, and
flexing the legs (especially the left leg) will alleviate some of the pain associated
with
, pancreatitis. The fetal position (with the legs drawn up to the chest) may
decrease the abdominal pain of pancreatitis.
1
Rationale:The priority nursing action is to assess the vital signs. This would
provide information about the amount of blood loss that has occurred and
provide a baseline by which to monitor the progress of treatment. The client
may be unable to provide subjective data until the immediate physical needs are
met. Although an abdominal examination and an assessment of the precipitating
events may be necessary, these actions are not the priority. Insertion of a
nasogastric tube is not the priority and will require a health care provider's
prescription; in addition, the vital signs should be checked before performing
this procedure.
Don't know?
3 of 66
Term
The nurse is performing discharge teaching for a client with chronic
pancreatitis. Which information should the nurse include?
1. Alcohol should be consumed in moderation.
2. Avoid caffeine because it may aggravate symptoms.
3. Diet should be high in carbohydrates, fats, and proteins.
4. Frothy, fatty stools indicate that enzyme replacement is working.
3
Rationale:With intravesical instillation, normally the medication is injected into the
bladder through a urethral catheter, the catheter is clamped or removed, and
the client is asked to retain the fluid for 2 hours. The client changes position
every 15
VERIFIED ANSWERS
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.
, 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
,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
inflammation will intensify the irritation of the posterior peritoneal wall with these
positions or movements. Positions such as sitting up, leaning forward, and
flexing the legs (especially the left leg) will alleviate some of the pain associated
with
, pancreatitis. The fetal position (with the legs drawn up to the chest) may
decrease the abdominal pain of pancreatitis.
1
Rationale:The priority nursing action is to assess the vital signs. This would
provide information about the amount of blood loss that has occurred and
provide a baseline by which to monitor the progress of treatment. The client
may be unable to provide subjective data until the immediate physical needs are
met. Although an abdominal examination and an assessment of the precipitating
events may be necessary, these actions are not the priority. Insertion of a
nasogastric tube is not the priority and will require a health care provider's
prescription; in addition, the vital signs should be checked before performing
this procedure.
Don't know?
3 of 66
Term
The nurse is performing discharge teaching for a client with chronic
pancreatitis. Which information should the nurse include?
1. Alcohol should be consumed in moderation.
2. Avoid caffeine because it may aggravate symptoms.
3. Diet should be high in carbohydrates, fats, and proteins.
4. Frothy, fatty stools indicate that enzyme replacement is working.
3
Rationale:With intravesical instillation, normally the medication is injected into the
bladder through a urethral catheter, the catheter is clamped or removed, and
the client is asked to retain the fluid for 2 hours. The client changes position
every 15
