Nokea
A client who has a history of an inguinal hernia is admitted to the hospital with sudden, severe abdominal pain, vomiting, and abdominal distention. The nurse should assess the client further for which of the following complications?
- A. Peritonitis.
- B. Incarcerated hernia.
- C. Strangulated hernia.
- D. Intestinal perforation.
Correct Answer: C
Rationale: Sudden, severe abdominal pain, vomiting, and distention in a client with an inguinal hernia suggest a strangulated hernia, where the herniated tissue loses blood supply, requiring urgent assessment. Peritonitis, incarceration, or perforation are less likely without additional signs. CN: Physiological adaptation; CL: Analyze
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A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
- A. Check the patient-controlled analgesia (PCA) pump function.
- B. Adjust the epidural catheter.
- C. Assess vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
- A. Urine output greater than 30 mL/hour.
- B. Systolic blood pressure greater than 110 mm Hg.
- C. Diastolic blood pressure greater than 90 mm Hg.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, 'When will my strength return?' Which of the following responses by the nurse is most appropriate?
- A. Your fatigue should be gone by now. We will evaluate you for a secondary infection.
- B. Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete.
- C. It is important for you to increase your activity level. That will help decrease your fatigue.
- D. It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months.
Correct Answer: D
Rationale: Fatigue is common during recovery from hepatitis A and typically resolves in 2-4 months (D). Secondary infection (A) is not indicated. Fatigue is not drug-related (B), and increasing activity prematurely (C) may worsen symptoms.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.