Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 86

1. A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric(NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

A) It is determined that he has no signs of wound infection
B) He is able to eat a full meal without evidence of nausea or vomiting
C) The nurse can detect bowel sounds in all four quadrants
D) His blood pressure returns to its preoperative baseline level or greater

2. A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de- compression. When preparing to insert a NG tube, the nurse measures from the:

A) Lower lip to the shoulder to the upper sternum
B) Tip of the nose to the lower lip to the umbilicus
C) End of the tube to the first measurement line on the tube
D) Tip of the nose to the ear lobe to the xiphoid process or midepigastric area

3. A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is:

A) After meals
B) Before meals
C) Every 2 hours
D) At bedtime

4. A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?

A) Fried chicken
B) Eggs
C) Tapioca
D) Cabbage

5. When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:

A) 30 minutes
B) 1 - 4 hours
C) 12 - 24 hours
D) 24 - 72 hours

1. Right Answer: C
Explanation: (A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. (D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.

2. Right Answer: D
Explanation: (A) This measurement is _50 cm (4849 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (B) This measurement is _50 cm (4748 cm). Fifty centimeters is considered the lengthnecessary for the distal end of the tube to be in place in the stomach. This measurement is too short. (C) This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-earxiphoid). (D) This is the correct measurement of 50 cm from the tip of the clients nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.

3. Right Answer: A
Explanation: (A) Bowel movements should be regulated at a specific time each day to prevent 'accidents.' Irrigating after meals takes advantage of the gastrocolic reflex and time of increased peristalsis, so better results may be produced. After meals is the normal time that peristalsis begins in most persons and evacuation of feces occurs. (B) Irrigating before meals may cause poor results because of decreased gastrocolic reflex and decreased peristalsis. (C) Irrigating a colostomy every 2 hours may produce hyperactivity of the bowel, leading to irritation and diarrhea. This would not aid in regulation of the bowel. (D) If irrigation of a colostomy were done at bedtime, there is greater chance of having an 'accident' during sleep. This would not be an advantageous practice of bowel regulation.

4. Right Answer: C
Explanation: (A) Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. (B) Eggs will cause odor-producing stools in individuals with all types of GI ostomies. (C) Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. (D) Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.

5. Right Answer: D
Explanation: (A) Synthetic cast materials harden in 315 minutes. Weight bearing is permitted in 1530 minutes. Drying time for plaster of Paris is about 2472 hours. (B, C)Plaster of Paris cast materials are heavier than synthetic materials and require a drying time of 2472 hours. Synthetic materials dry within 30 minutes. (D) Plaster of Paris cast materials are heavier thansynthetic materials and require a longer period to set and dry. Even though setting time (hardening) is only 315 minutes, the drying time for plaster of Paris is 2472 hours. This depends on the size and thickness of the cast, exposure to air, and humidity in the air.

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