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The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurse’s priority when monitoring for GI bleeding?
- A. The 40-year-old client who is positive for Helicobacter pylori (H. pylori)
- B. The 45-year-old client who drinks 4 ounces of alcohol a day
- C. The 70-year-old client who takes daily baby aspirin of 81 mg
- D. The 30-year-old pregnant client taking acetaminophen prn
Correct Answer: C
Rationale: A. The presence of H. pylori has not been proven to predispose to GI bleeding. B. Although alcohol is associated with gastric mucosal injury, its causative role in bleeding is unclear. C. It is most important for the nurse to monitor the 70-year-old client who is taking aspirin. The client has two risk factors for GI bleeding: age and taking aspirin. D. Pregnancy and acetaminophen usage do not predispose to GI bleeding.
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The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. Which question should the nurse ask to identify behaviors suggesting bulimia?
- A. When was the last time you exercised?
- B. What over-the-counter medications do you take?
- C. How long have you had a positive self-image?
- D. Do you eat a lot of high-fiber foods for bowel movements?
Correct Answer: B
Rationale: Asking about OTC medications identifies purging behaviors (e.g., laxatives, diuretics) common in bulimia. Exercise, self-image, and fiber intake are less specific.
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.
The nurse is assigned to care for four clients. The nurse should plan to assess which client first?
- A. The client with ascites who is having mild dyspnea with activity
- B. The client with a peptic ulcer who now has severe vomiting
- C. The client who had a colonoscopy and is having diarrheal stools
- D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes
Correct Answer: D
Rationale: D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes should be attended to first. Generalized rash indicates an allergic reaction. This could develop into an anaphylactic reaction. B. The client with a peptic ulcer who now has severe vomiting should be attended to second. Vomiting in PUD may indicate a complication such as mechanical obstruction from scarring. C. The client who had a colonoscopy and is having diarrheal stools should be attended to third. Diarrhea may have been the indication for the client’s colonoscopy or a side effect of the bowel prep. A. The client with ascites who is having mild dyspnea with activity can be attended to last. The dyspnea is usually due to the enlarged abdomen.
The client is admitted to a hospital for medical management of acute diverticulitis. The nurse should anticipate that this client’s treatment plan will include which component?
- A. NPO (nothing per mouth) status
- B. Frequent ambulation
- C. Prescribed antibiotics
- D. Antiemetic medication
- E. Deep breathing every 2 hours
Correct Answer: A, C
Rationale: The nurse should plan for the client to be NPO. Medical management for diverticulitis includes resting the bowel. NPO status will help to achieve this. B. Ambulation is not encouraged; resting the body promotes bowel rest. C. Broad-spectrum antibiotics effective against known enteric pathogens are used in treating every stage of diverticulitis. D. Nausea is not a concern with diverticulitis. E. The client did not have surgery; there is no need for deep breathing every 2 hours.