Nokea
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric area along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following?
- A. An intestinal obstruction has developed
- B. Additional ulcers have developed
- C. The esophagus has become inflamed
- D. The ulcer has perforated
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following tasks should be included in the immediate postoperative management of a client who has undergone gastric resection?
- A. Monitoring gastric pH to detect complications
- B. Assessing for bowel sounds
- C. Providing nutritional support
- D. Monitoring for symptoms of hemorrhage
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?
- A. Digoxin (Lanoxin)
- B. Indomethacin (Indocin)
- C. Furosemide (Lasix)
- D. Propranolol hydrochloride (Inderal)
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
- A. Check that the hemostat is on the bedside
- B. Monitor IV fluids for the shift
- C. Regularly assess respiratory status
- D. Check that the balloon is deflated on a regular basis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is evaluating the plan of care for a client with peptic ulcer disease with a nursing diagnosis of Acute Pain. The nurse would determine that the client has not met the expected outcomes if the client states
- A. That pain is relieved with histamine H2 receptor antagonists.
- B. That irritating foods have been eliminated from the diet.
- C. The client is being awakened at 2 AM with heartburn.
- D. The client has absence of pain before meals.
Correct Answer: C
Rationale: Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that the pain is relieved or prevented with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2 receptor antagonist or an additional dose of antacid before the time when pain awakens the client.
Which of the following symptoms best describes Murphy's sign?
- A. Periumbilical ecchymosis exists
- B. On deep palpation and release, pain is elicited
- C. On deep inspiration, pain is elicited and breathing stops
- D. Abdominal muscles are tightened in anticipation of palpation
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.