GI
A nurse is caring for a client receiving bolus enteral tube feedings via a nasogastric tube. Which action is highest priority to prevent complications?
Check tube placement and residuals before each feeding
A nurse is caring for a client with thrombocytopenia. Which intervention is the highest priority?
Monitor for signs of bleeding
This is the earliest indicator of decreased perfusion.
What is altered mental status?
A nurse is caring for a client 1 day post below-the-knee amputation (BKA). Which positioning intervention is appropriate to prevent complications?
A. Elevate the residual limb on pillows for the entire day
B. Keep the residual limb flat and extended while the client is lying prone
C. Place the client in a sitting position with the hip and knee flexed at all times
D. Cross the legs when the client is supine
Keep the residual limb flat and extended while the client is lying prone
Goal: Prevent hip and knee contractures, especially knee flexion contractures after BKA.
Correct positioning:
Residual limb flat on bed while supine for short periods
Prone positioning 20–30 minutes several times/day to stretch hip flexors and prevent contractures
Avoid prolonged elevation after the first 24 hours → may cause hip/knee flexion contractures
Avoid crossing legs → increases risk for contractures
Heart rate 80 bpm, regular rhythm, P wave before each QRS
NSR
A client with ulcerative colitis asks what foods to avoid during a flare-up. Which instruction is most appropriate?
A. Eat high-residue foods like raw vegetables
B. Avoid dairy, high-fat, and spicy foods
C. Drink carbonated beverages with meals
D. Increase intake of whole grains
Avoid dairy, high-fat, and spicy foods
During flare-ups, low-residue, low-fat, bland foods reduce bowel irritation
High-residue foods increase diarrhea
Dairy may worsen symptoms if lactose intolerant
Which thrombocytopenic client should the nurse assess first?
A. A client with platelets of 45,000/mm³ who has petechiae on the arms
B. A client with platelets of 80,000/mm³ who reports nosebleeds
C. A client with platelets of 25,000/mm³ who has coffee-ground emesis
D. A client with platelets of 60,000/mm³ who has fatigue and mild bruising
A client with platelets of 25,000/mm³ who has coffee-ground emesis
These three findings are most indicative of right-sided heart failure.
JVD, Edema, Hepata/splenomegaly
A client is 1 day postoperative from a below-the-knee amputation (BKA). Which nursing action is highest priority?
A. Elevate the residual limb on pillows
B. Monitor for bleeding and assess distal circulation
C. Teach the client about phantom limb pain
D. Encourage use of a prosthesis as soon as possible
Monitor for bleeding and assess distal circulation
Postoperative hemorrhage and impaired circulation are life-threatening complications.
A client with hypertension is admitted to the unit. Which assessment is most important?
A. Daily weight
B. Lung sounds
C. Neurological status
D. Heart rate
Uncontrolled HTN increases risk for stroke; neuro assessment is priority.
A client with Crohn’s disease has the following labs:
Hgb 9.8 g/dL (low)
Hct 28% (low)
Serum albumin 2.8 g/dL (low)
Which problem is the nurse most concerned about?
A. Infection
B. Malnutrition
C. Dehydration
D. Electrolyte imbalance
Malnutrition
Crohn’s affects small intestine absorption → nutrient deficiencies
Low H/H indicates anemia; low albumin indicates protein deficiency
Dehydration and electrolyte issues are possible but labs point to malnutrition
A nurse is administering a blood transfusion to a client with anemia. Thirty minutes after starting, the client reports shortness of breath, headache, and anxiety, SOB, and elevated BP. What is the priority action?
Interventions for TACO:
Slow or temporarily stop the transfusion
Place upright to reduce pulmonary congestion
Administer oxygen and diuretics as ordered
Notify provider but the immediate action is supportive measures.
2 common complications of an MI
A nurse is teaching a client about hip precautions after a total hip replacement. Which statement by the client indicates correct understanding?
A. “I can bend my hip more than 90 degrees to put on shoes.”
B. “I should cross my legs while sitting to relieve pressure.”
C. “I will use a raised toilet seat and avoid low chairs.”
D. “I can twist my hip when reaching for objects on the floor.”
I will use a raised toilet seat and avoid low chairs.”
Post-hip replacement precautions prevent dislocation:
Avoid hip flexion >90°
Do not cross legs
Avoid twisting the hip
Use raised toilet seats, chairs, and assistive devices
Statements A, B, D indicate risk for dislocation
Which statement by a client taking lisinopril indicates correct understanding?
A. “I should stop this medication if my BP improves.”
B. “I will change positions slowly.”
C. “I should increase potassium intake.”
D. “A persistent cough is common
“I will change positions slowly.”
ACE inhibitors can cause orthostatic hypotension.
A client with GERD reports burning chest pain after meals, worse when lying down. Which intervention should the nurse implement first?
A. Administer antacid as prescribed
B. Encourage the client to eat three large meals daily
C. Place the client supine after meals
D. Instruct the client to avoid spicy foods
Administer antacid as prescribed
The client is experiencing acid reflux symptoms (heartburn).
Priority is to relieve pain and neutralize acid.
Other interventions are important for long-term management but not immediate relief.
What is one of the treatments for polycythemia vera?
Phlebotomy
Low-dose aspirin
Hydration
This condition is an absolute contraindication to thrombolytic therapy.
Active bleeding
A nurse is caring for a client who had a total hip replacement 1 day ago. Which assessment finding is the highest priority?
A. Mild incisional pain rated 6/10
B. The client’s affected leg is internally rotated and shortened
C. The client reports mild nausea
D. Dressing shows moderate serosanguinous drainage
The client’s affected leg is internally rotated and shortened
Rationale:
Internal rotation and shortening of the leg may indicate hip dislocation, a postoperative orthopedic emergency.
A client’s ECG shows a regular rhythm at 150 bpm with narrow QRS complexes and a sawtooth pattern between QRS complexes. What rhythm is this?
Atrial flutter
A client who had gastric bypass surgery reports nausea, abdominal cramping, dizziness, and sweating about 20 minutes after eating a meal. What is the priority nursing intervention?
A. Encourage the client to drink fluids with meals
B. Reassure the client this is a normal post-op finding
C. Place the client supine with legs elevated and notify the provider if severe
D. Instruct the client to eat small, frequent meals low in simple carbohydrates
nstruct the client to eat small, frequent meals low in simple carbohydrates
These symptoms are classic for dumping syndrome, which occurs when high-sugar or high-carb foods rapidly enter the small intestine, causing fluid shifts and hypoglycemia.
Priority teaching and management:
Eat small, frequent meals
Avoid simple sugars
Eat high-protein foods
Lie down for 20–30 minutes after meals to slow gastric emptying
A client with sickle cell anemia is admitted with a vaso-occlusive crisis. Which is the highest priority nursing assessment?
A. Monitor hydration status
B. Assess pain level
C. Check temperature
D. Evaluate nutritional intake
Pain from vaso-occlusion is the hallmark of sickle cell crisis and is the priority concern on NCLEX.
What type of MI is most concerning and requires immediate intervention?
STEMI
A client is admitted with a closed tibia fracture. Which assessment finding requires immediate intervention?
A. Moderate pain at the fracture site rated 5/10
B. Swelling and bruising around the lower leg
C. Numbness and tingling in the toes
D. The client reports anxiety about being immobilized
Numbness, tingling, or cool/pale extremity indicate neurovascular compromise → possible compartment syndrome or arterial injury.
Priority NCLEX principle: ABCs → circulation and perfusion first.
A client presents with BP 198/120 mmHg and severe headache. What is the nurse’s priority action?
A. Administer oral antihypertensive
B. Recheck BP in 30 minutes
C. Notify the provider immediately
D. Encourage deep breathing
Notify the provider immediately
This is a hypertensive emergency → risk of organ damage.