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A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
- A. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- B. Give a prescribed analgesic for temperature above 101°F (38.3° C).
- C. Place an indwelling urinary catheter and attach a bedside drainage unit.
- D. Send the client to x-ray for a flat plate of the abdomen.
Correct Answer: A
Rationale: Inserting an NGT with low intermittent suction decompresses the stomach, removes gastric contents, and relieves vomiting and pain, addressing the acute symptoms of peptic ulcer exacerbation first.
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To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Apical heart rate of 100 to 110 beats/minute.
- B. Redness and edema noted at the incision site.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 1 to 10.
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output post-TUNA is essential to identify potential complications such as urinary retention, infection, or bleeding, ensuring timely intervention.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do you have any dry patches on your feet and hands?
- D. Do your family members share combs and brushes?
Correct Answer: A
Rationale: Asking if everyone at home has had varicella helps determine the risk of transmission of the varicella-zoster virus, which causes herpes zoster, to non-immune individuals, informing isolation precautions.
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
- A. Obtain a prostate-specific antigen blood level test.
- B. Take vitamin supplements.
- C. Increase physical activity.
- D. Consume a high protein diet.
Correct Answer: C
Rationale: Increasing physical activity helps maintain a healthy weight and improves pelvic blood flow, reducing BPH risk factors, unlike PSA testing, supplements, or high-protein diets, which lack direct preventive benefits.