Nokea
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
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The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
A client returns from having had abdominal surgery. Her vital signs are stable. She says she is thirsty. What should the nurse give her initially?
- A. Orange juice
- B. Milk
- C. Ice chips
- D. Mouth wash
Correct Answer: C
Rationale: Ice chips are safe to relieve thirst initially post-abdominal surgery, as clear liquids are introduced gradually until peristalsis returns.
The client with a history of a duodenal ulcer is hospitalized with upper abdominal discomfort and projectile vomiting that has a foul odor. The nurse immediately notifies the HCP, concluding that the client may have developed which complication?
- A. Gastric perforation
- B. Gastrointestinal hemorrhage
- C. Gastric outlet obstruction
- D. Helicobacter pylori infection
Correct Answer: C
Rationale: A. Symptoms of perforation include severe abdominal pain; vomiting usually does not occur. B. The client with GI hemorrhage would have bright red or coffee-ground-colored emesis. C. Symptoms of gastric outlet obstruction include abdominal pain and projectile vomiting when the stomach fills enough to stimulate afferent nerve fibers relaying information to the vomiting center in the brain. The emesis may have a foul odor or contain food particles if the contents have been dormant in the stomach for a prolonged time period. D. Infection with H. pylori is not a complication of PUD; rather, it is a major cause of peptic ulcers.
The nurse is caring for the client who had a vertical banded gastroplasty. The nurse teaches that nausea can occur after this surgery from which situation?
- A. The stomach pouch becomes overfilled.
- B. The lower half of the stomach becomes spastic.
- C. The duodenum incision becomes inflamed.
- D. The dumping syndrome from a high-protein meal.
Correct Answer: A
Rationale: A. A small pouch (15—20 mL capacity) is constructed in the upper part of the stomach during vertical banded gastroplasty. Overfilling of this pouch stimulates afferent nerve fibers, which relay information to the chemoreceptor trigger zone in the brain, causing nausea. B. The function of the lower half of the stomach is not affected with a vertical banded gastroplasty. C. The duodenum is not incised during a vertical banded gastroplasty. D. Dumping syndrome is more likely to occur from a meal high in simple carbohydrates, not protein.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
- A. Notify the surgeon immediately.
- B. Instruct the client to splint the incision.
- C. Assess the abdominal wound incision.
- D. Administer pain medication intravenously.
Correct Answer: C
Rationale: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.