Nokea
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
- A. Distended, hard, and rigid abdomen
- B. Clay-colored stool
- C. Radiating sharp pain in the right shoulder
- D. Bile-stained emesis
Correct Answer: A
Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.
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The client with chronic renal failure who is on a low-sodium diet should avoid which of the following foods?
- A. Fresh fruits.
- B. Canned soups.
- C. Lean meats.
- D. Whole grain bread.
Correct Answer: B
Rationale: Canned soups are high in sodium, which can lead to fluid retention and hypertension in clients with chronic renal failure who are on a low-sodium diet. Fresh fruits, lean meats, and whole grain bread are generally lower in sodium and can be included in a low-sodium diet. Lean meats provide essential protein, fresh fruits offer vitamins and minerals, and whole grain bread provides fiber, making them suitable choices for individuals with chronic renal failure.
After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
- A. Irregular pulse rhythm
- B. Bile-colored emesis
- C. ST elevation in three leads
- D. Complaint of radiating jaw pain
Correct Answer: C
Rationale: ST elevation in three leads is a critical finding that suggests myocardial infarction, requiring immediate attention. This finding indicates ischemia or injury to the heart muscle. Choices A, B, and D are not as critical in this scenario. Irregular pulse rhythm may be concerning but does not indicate an immediate life-threatening condition like myocardial infarction. Bile-colored emesis and complaint of radiating jaw pain are relevant but not as indicative of a myocardial infarction as ST elevation in three leads.
The healthcare provider assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
- A. Hyperaldosteronism causing increased sodium transport ion in renal tubules
- B. Decreased portacaval pressure with greater collateral circulation
- C. Decreased renin-angiotensin response related to increased renal blood flow
- D. Hypoalbuminemia that results in decreased colloidal oncotic pressure
Correct Answer: D
Rationale: In clients with cirrhosis, hypoalbuminemia leads to decreased colloidal oncotic pressure. This reduction in oncotic pressure contributes to the development of edema in the feet and legs (pitting edema) and ascites in the abdomen. Hyperaldosteronism (choice A) would lead to sodium retention but is not the primary mechanism behind edema and ascites in cirrhosis. Decreased portacaval pressure with greater collateral circulation (choice B) is not directly related to the pathophysiology of edema and ascites in cirrhosis. Decreased renin-angiotensin response related to increased renal blood flow (choice C) does not play a significant role in the development of edema and ascites in cirrhosis compared to the impact of hypoalbuminemia on colloidal oncotic pressure.
A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?
- A. Verify pedal pulses using a Doppler pulse device
- B. Evaluate the application of the splint to the left leg
- C. Offer ice chips and clear oral liquids
- D. Monitor the left leg for pain, pallor, paresthesia, paralysis, pressure
Correct Answer: B
Rationale: Evaluating the application of the splint is the priority as it ensures it is not too tight, which could impair circulation and exacerbate the diminished pulses. Verifying pedal pulses with a Doppler pulse device may be indicated but does not directly address the immediate concern of proper splint application. Offering ice chips and clear oral liquids would not address the issue of diminished distal pulses. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is important but would not directly address the cause of the diminished pulses in this scenario.
A client with chronic renal failure is receiving erythropoietin therapy. The nurse should assess the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hyperglycemia.
- D. Hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Hypertension. Erythropoietin therapy can lead to an increase in blood pressure, making hypertension a common side effect that the nurse should closely monitor. Hypotension (choice A) is not typically associated with erythropoietin therapy. Hyperglycemia (choice C) and hypercalcemia (choice D) are not commonly linked to erythropoietin therapy in clients with chronic renal failure, making them incorrect choices.