Nokea
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
You may also like to solve these questions
The client with Crohn’s disease has undergone a barium enema that showed strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of which complication?
- A. Peritonitis
- B. Obstruction
- C. Malabsorption
- D. Fluid imbalance
Correct Answer: B
Rationale: A. Peritonitis would not be an expected consequence of a bowel stricture. B. The nurse should monitor for signs of a bowel obstruction. Bowel strictures are a common complication of Crohn’s disease and can result in an acute bowel obstruction. C. Malabsorption would not be an expected consequence of a bowel stricture. D. Fluid balance would be affected once total obstruction develops.
The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation?
- A. Wear a high-filtration mask when around chemicals.
- B. Eat several servings of cruciferous vegetables daily.
- C. Take a multiple vitamin every day.
- D. Do not engage in high-risk sexual behaviors.
Correct Answer: B
Rationale: Cruciferous vegetables (e.g., broccoli, cauliflower) are high in fiber and antioxidants, which may reduce colon cancer risk. Masks, vitamins, and sexual behaviors are less directly linked to colon cancer prevention.
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
- A. Pain related to heartburn from gastric reflux.
- B. Aspiration related to regurgitation of food accumulated in the diverticula.
- C. Constipation related to anatomical changes of the sigmoid colon.
- D. Altered nutrition, less than body requirements related to dysphagia.
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.
The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?
- A. Mark the drainage on the dressing with the time and date.
- B. Change the dressing immediately using sterile technique.
- C. Notify the health-care provider immediately.
- D. Reinforce the dressing with a sterile gauze pad.
Correct Answer: C
Rationale: Dark reddish brown drainage one day post-surgery suggests possible bleeding or dehiscence, warranting immediate notification of the HCP for evaluation. Marking or reinforcing the dressing delays action, and changing the dressing is secondary.
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.