Nokea
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client blood pressure when long days was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?
- A. Administer ibuprofen (Motrin).
- B. Call the Rapid Response Team.
- C. Start a large-bore IV with normal saline.
- D. Tell the client to remain lying down.
Correct Answer: C
Rationale: This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is not the priority.
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A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?
- A. Arrange a dietary consult.
- B. Increase the client's fluid intake.
- C. Limit the client's foods.
- D. Make the client NPO.
Correct Answer: A
Rationale: The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to a registered dietitian would be extremely helpful. Food and fluid intake is complicated and needs planning. The client should not be NPO.
A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first?
- A. Assist the client back to bed.
- B. Notify the provider immediately.
- C. Put on a pair of gloves.
- D. Take a set of vital signs.
Correct Answer: C
Rationale: All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid communication with blood or body fluids.
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.)
- A. Achlorhydria
- B. Chronic atrophic gastritis
- C. Helicobacter pylori infection
- D. Iron deficiency anemia
- E. Pernicious anemia
Correct Answer: A,B,C,E
Rationale: Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for developing gastric cancer. Iron deficiency anemia is not a risk factor.
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.)
- A. Ask a second nurse to double-check the blood.
- B. Prime the IV tubing with normal saline.
- C. Prime the IV tubing with dextrose in water.
- D. Take and record a set of vital signs.
- E. Teach the client about reaction manifestations.
Correct Answer: A,B,D,E
Rationale: Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identification), primes the IV tubing with normal saline, takes and records a set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.)
- A. Anorexia
- B. Dyspepsia
- C. Intolerance of fatty foods
- D. Pernicious anemia
- E. Nausea and vomiting
Correct Answer: C,D
Rationale: Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.