Nokea
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.)
- A. Ask a second nurse to double-check the blood.
- B. Prime the IV tubing with normal saline.
- C. Prime the IV tubing with dextrose in water.
- D. Take and record a set of vital signs.
- E. Teach the client about reaction manifestations.
Correct Answer: A,B,D,E
Rationale: Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identification), primes the IV tubing with normal saline, takes and records a set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
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The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.)
- A. Alcohol
- B. Caffeine
- C. Corticosteroids
- D. Fruit juices
- E. Nonsteroidal anti-inflammatory drugs (NSAIDs)
Correct Answer: A,B,C,E
Rationale: Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is not a risk factor, although in some people it does cause distress.
A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first?
- A. Assist the client back to bed.
- B. Notify the provider immediately.
- C. Put on a pair of gloves.
- D. Take a set of vital signs.
Correct Answer: C
Rationale: All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid communication with blood or body fluids.
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should be reported to the surgeon immediately?
- A. Albumin: 2.1 g/dL
- B. Hematocrit: 28%
- C. Hemoglobin: 8.1 g/dL
- D. International normalized ratio (INR): 4.2
Correct Answer: D
Rationale: An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?
- A. Arrange a dietary consult.
- B. Increase the client's fluid intake.
- C. Limit the client's foods.
- D. Make the client NPO.
Correct Answer: A
Rationale: The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to a registered dietitian would be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.
A client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.)
- A. Canned unsweetened apricots
- B. Canned cake
- C. Milk and water
- D. Potato soup
- E. Steamed broccoli
Correct Answer: A,D
Rationale: Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to moderate-carbohydrate diet. Cake and other sweets must be avoided. Milk products and sweet drinks such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.