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A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Bowel sounds active in all quadrants.
- B. Blood pressure of 110/70 mm Hg.
- C. Rigid, board-like abdomen.
- D. Heart rate of 90 beats per minute.
Correct Answer: C
Rationale: The correct answer is C: Rigid, board-like abdomen. This finding suggests peritonitis, a serious complication of peptic ulcer disease, requiring immediate medical intervention. A: Active bowel sounds are expected. B: Blood pressure is within normal range. D: Heart rate is slightly elevated but not a critical finding. In summary, a rigid abdomen indicates peritonitis and requires urgent attention compared to the other choices.
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A patient with schizophrenia is prescribed olanzapine. What is an important side effect for the healthcare provider to monitor?
- A. Hypertension
- B. Weight gain
- C. Hypoglycemia
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine is known to cause metabolic side effects, including weight gain. This is important to monitor as it can lead to various health issues such as diabetes and cardiovascular problems. Hypertension (A), hypoglycemia (C), and bradycardia (D) are not commonly associated with olanzapine use, making them less likely side effects to monitor in this case.
A client with peptic ulcer disease is prescribed ranitidine (Zantac). Which statement by the client indicates the need for further teaching?
- A. I will take this medication at bedtime.
- B. I need to avoid smoking while taking this medication.
- C. I should take this medication with meals.
- D. This medication will help reduce stomach acid.
Correct Answer: C
Rationale: Rationale:
C is the correct answer. Ranitidine is usually taken on an empty stomach to maximize its effectiveness in reducing stomach acid production. Therefore, taking it with meals would decrease its efficacy. A, B, and D are incorrect because taking ranitidine at bedtime is common practice, smoking can worsen ulcer symptoms, and ranitidine does indeed reduce stomach acid.
A patient with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. What is the primary purpose of this medication?
- A. Reduce mucus production
- B. Relieve bronchospasm
- C. Suppress cough
- D. Thin respiratory secretions
Correct Answer: B
Rationale: The correct answer is B: Relieve bronchospasm. Tiotropium is an anticholinergic medication that acts by relaxing the muscles around the airways, thereby helping to relieve bronchospasm in patients with COPD. This results in improved airflow and reduced shortness of breath.
A: Reduce mucus production - This is incorrect as tiotropium does not directly affect mucus production but rather focuses on bronchospasm relief.
C: Suppress cough - Tiotropium may help with cough associated with COPD by improving airflow, but its primary purpose is not to suppress cough.
D: Thin respiratory secretions - Tiotropium does not have a direct effect on thinning respiratory secretions; its main action is bronchodilation to relieve bronchospasm in COPD.
A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?
- A. Complete blood count (CBC)
- B. Prothrombin time (PT)/INR
- C. Partial thromboplastin time (PTT)
- D. Serum potassium level
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT)/INR. This is because warfarin is a medication that affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. PT/INR is the specific laboratory test used to monitor the effectiveness of warfarin therapy. PT measures how long it takes for blood to clot, while INR standardizes the PT results. Monitoring PT/INR helps to ensure that the patient is within the target therapeutic range for anticoagulation.
Incorrect choices:
A: Complete blood count (CBC) - CBC does not directly assess the effectiveness of warfarin therapy.
C: Partial thromboplastin time (PTT) - PTT is used to monitor the effectiveness of heparin therapy, not warfarin.
D: Serum potassium level - Monitoring serum potassium level is not directly related to assessing the effectiveness of warfarin therapy.
After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?
- A. Pedal pulses.
- B. Breath sounds.
- C. Gag reflex.
- D. Vital signs.
Correct Answer: D
Rationale: The correct answer is D: Vital signs. After paracentesis, monitoring vital signs is crucial as fluid removal can lead to changes in blood pressure, heart rate, and overall fluid balance. Hypotension or tachycardia may indicate hypovolemia or shock. Pedal pulses (A) are important but not as critical post-paracentesis. Breath sounds (B) are important for respiratory assessment but not directly related to fluid removal. Gag reflex (C) is unrelated to paracentesis and not a priority post-procedure.