Nokea
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?
- A. Measure capillary glucose level.
- B. Encourage ambulation in the room.
- C. Monitor for bloody diarrheal stools.
- D. Obtain vital sign measurements.
Correct Answer: D
Rationale: Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness, indicating peritonitis, a serious complication of IBD. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, guiding appropriate interventions and treatments.
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The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
- A. Hepatorenal failure.
- B. Acute pancreatitis.
- C. Surgical site infection.
- D. Biliary duct obstruction.
Correct Answer: B
Rationale: Acute pancreatitis is indicated by fever, upper abdominal pain radiating to the back, vomiting, and elevated amylase and lipase levels, likely triggered by the cholecystectomy.
A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- A. Pupillary changes to ipsilateral dilation.
- B. Left-sided facial drooping and dysphagia.
- C. Orientation to person and place only.
- D. Unequal bilateral hand grip strengths.
Correct Answer: A
Rationale: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Redness and edema noted at the incision site.
- B. Apical heart rate of 100 to 110 beats/minute.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 0 to 10.
Correct Answer: C
Rationale: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.
Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. Select the interdisciplinary team members who should assist the client in recovery.
- A. Occupational Therapist
- B. Speech Therapist
- C. Case manager
- D. Physical therapist
- E. Chief Nursing Officer
- F. Pharmacy Technician
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address stroke-related impairments in daily activities, communication, and mobility, while a case manager coordinates care and discharge planning.
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 decrease in output is critical to detect urinary retention or obstruction, potential complications of TUNA.