Nokea
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
- A. Administer an antiemetic.
- B. Prepare to insert a nasogastric (NG) tube.
- C. Collect data regarding recent client stressors.
- D. Place the client in a modified Trendelenburg position.
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.
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The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take for long-term management?
- A. Allopurinol.
- B. Colchicine.
- C. Indomethacin.
- D. Prednisone.
Correct Answer: A
Rationale: Allopurinol reduces uric acid production for long-term gout management.
A client with a moderate level of anxiety is pacing quickly in the hall. As the nurse approaches, he states, 'Help me. I can't take it anymore.' Which of the following would be the best response initially?
- A. It would be best if you would lie down until you're calmer.'
- B. Let's go to a quieter area where we can talk if you want.'
- C. Try doing your relaxation exercises to calm down.'
- D. I'll get some medicine to help you relax.'
Correct Answer: B
Rationale: Offering to talk in a quieter area de-escalates anxiety and provides a supportive environment.
A client with a diagnosis of gout is prescribed febuxostat (Uloric). The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking febuxostat with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.