Nokea
A client is having an esophagealgrosodendonescoropy (EGD) and has been given midazolam hydrochloride (Vessel). The clients respiratory rate is 8 breaths/min. What action by the nurse is best?
- A. Administerin valoxone (Vessel).
- B. Call the Rapid Response Team.
- C. Provide physical stimulation.
- D. Ventilate with a bag-valre-mask.
Correct Answer: C
Rationale: For an EGD, clients are given mild sedation but should still be able to follow commands. For shallow or slow respirations after sedation is given, the nurse's first action is to provide physical stimulation such as a sternal rub and directions to breathe deeply. Naloxone is not the antidote for midazolam (Versed). The Rapid Response Team is not needed at this point. The client does not need manual ventilation.
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A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?
- A. Auscultate the abdomen.
- B. Notify the provider immediately.
- C. Order an abdominal flat-plate x-ray.
- D. Palpate the abdomen to assess size.
Correct Answer: B
Rationale: The observation could indicate an abdominal aortic aneurysm, which could be life-threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated, but it is not the priority. Auscultation is part of the assessment, but the nurse's priority action is to notify the provider.
The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ?
- A. Kidney
- B. Liver
- C. Spleen
- D. Stomach
Correct Answer: B
Rationale: Severe acute or chronic liver damage leads to a prolonged PT secondary to impaired synthesis of clotting factors. The other organs are not directly related to this issue.
A client who has been taking antibiotics reports severe, watery diarrhea. About which test does the nurse teach the client?
- A. Colonoscopy.
- B. Enzyme-linked immunosorbent assay (ELISA) toxin A+B
- C. Ova and parasites
- D. Stool culture
Correct Answer: B
Rationale: Severe, watery diarrhea after antibiotic use may indicate Clostridioides difficile infection. The ELISA toxin A+B test is used to detect toxins produced by C. difficile. A colonoscopy, ova and parasites test, or stool culture are not typically warranted for this scenario unless further evaluation is needed.
The student nurse studying the gastrointestinal system understands that chyme refers to what?
- A. Hormenization that reduces acidity.
- B. Liquedied food ready for digestion
- C. Nutrients after being absorbed
- D. Secretions that help digest food
Correct Answer: B
Rationale: Before being digested, food must be broken down into a liquid form. This liquid is called chyme. Secretin is the hormone that inhibits acid production and decreases gastric motility. Absorption is carried out so the nutrients produced by digestion move from the lumen of the GI tract into the body's circulatory system for uptake into individual cells. The secretions that help digest food include hydrochloric acid, bile, and digestive enzymes.
A nurse is examining a client reporting right upper quadrant (RUQ) abdominal pain. What technique should the nurse use to assess this clients abdomen?
- A. Auscultate after palpating.
- B. Avoid any palpation.
- C. Palpate the RUQ last.
Correct Answer: C
Rationale: If pain is present in a certain area of the abdomen, that area should be palpated last to keep the client from tensing up, which could affect the rest of the examination. Auscultation of the abdomen occurs prior to palpation to avoid altering bowel sounds.