Nokea
A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
- A. Profuse vomiting with fecal odor
- B. Epigastric abdominal distention
- C. Intermittent abdominal cramping
- D. Ribbon-like stools or diarrhea
- E. Metabolic acidosis
- F. Severe fluid and electrolyte imbalance
Correct Answer: A,B,C,D,E,F
Rationale: All are potential findings in LBO due to mechanical obstruction, bacterial overgrowth, and fluid shifts.
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A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Provide oral care every 4 hours and as needed
- B. Position the head of the client's bed in the flat position
- C. Turn the client every 4 hours
- D. Provide humidity by maintaining moisture within the ventilator tubing
Correct Answer: A
Rationale: Regular oral care reduces bacterial colonization that could lead to VAP.
A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?
- A. Label the feeding bag with the date and time of the start of the feeding.
- B. Aspirate the client's stomach contents.
- C. Hang the feeding bag 30 cm (12 inches) above the client.
- D. Warm the feeding to room temperature.
Correct Answer: B
Rationale: Aspirating the client's stomach contents is the first action the nurse should take to confirm correct placement of the NG tube before administering feeding.
A client is admitted to the hospital with suspected rheumatic endocarditis. Which of the following laboratory tests would assist in confirming the diagnosis?
- A. Liver enzymes
- B. Serum albumin
- C. Throat culture
- D. Arterial blood gases
Correct Answer: C
Rationale: Throat culture can identify streptococcal infection preceding rheumatic fever/endocarditis.
A nurse in the emergency department is caring for a client who had a seizure and became unresponsive after stating they had a sudden, severe headache. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurological disorders should the nurse suspect?
- A. Embolic stroke
- B. Thrombotic stroke
- C. Transient ischemic attack (TIA)
- D. Hemorrhagic stroke
Correct Answer: D
Rationale: The sudden severe headache followed by seizure and unresponsiveness with elevated BP suggests hemorrhagic stroke.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen therapy
- B. Start an IV infusion of Lactated Ringer's
- C. Initiate cardiac monitoring
- D. Give morphine IV
Correct Answer: A
Rationale: Oxygen is first priority to address hypoxemia caused by PE.