Nokea
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child's mother starting to place hot, wet washcloths on her daughter's abdomen so that 'she will feel better.' The nurse explains that this action is contraindicated because heat:
- A. can cause the appendix to rupture and cause peritonitis.
- B. can mask symptoms of acute appendicitis.
- C. will increase peristalsis throughout the abdomen.
- D. will arrest progression of the disease.
Correct Answer: A
Rationale: Heat can increase inflammation and blood flow, risking appendix rupture and peritonitis in appendicitis.
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While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?
- A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour
- B. Initiate nasojejunal enteral feedings with a low-fat formula
- C. Imipenem-cilastatin 500 mg IV every 6 hours
- D. Up to chair for meals and ambulate four times daily
- E. Position left side-lying with head of bed elevated 30 degrees
- F. Insert a urinary catheter; monitor urine output every 2 hours
Correct Answer: A, B, C, F
Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.
The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
The 85-year-old male client diagnosed with cancer of the colon asks the nurse, 'Why did I get this cancer?' Which statement is the nurse's best response?
- A. Research shows a lack of fiber in the diet can cause colon cancer.
- B. It is not common to get colon cancer at your age; it is usually in young people.
- C. No one knows why anyone gets cancer, it just happens to certain people.
- D. Women usually get colon cancer more often than men but not always.
Correct Answer: A
Rationale: Low dietary fiber is a known risk factor for colon cancer, as it slows bowel transit and increases exposure to carcinogens. Colon cancer is common in older adults, not younger ones, and gender differences are minimal.
Which problem is most appropriate for the nurse to identify for the client with diarrhea?
- A. Alteration in skin integrity.
- B. Chronic pain perception.
- C. Fluid volume excess.
- D. Ineffective coping.
Correct Answer: A
Rationale: Diarrhea can cause perianal skin breakdown, making alteration in skin integrity the most appropriate problem. Pain is less common, fluid volume is deficient, and coping is secondary.