Nokea
A male client tells his nurse that he has had an ulcer in the past and is afraid it is 'flaring up again.' The nurse begins to ask him specific questions about his symptoms. The nurse knows that a symptom that might indicate a serious complication of an ulcer is:
- A. Pain in the middle of the night
- B. A bowel movement every 3-5 days
- C. Melena
- D. Episodes of nausea and vomiting
Correct Answer: C
Rationale: Clients with ulcers generally experience abdominal pain. It is common to have pain in the early morning hours with an ulcer. Constipation is not a symptom associated with ulcers and would indicate a need to look at other factors. Melena is blood in the stools. This could indicate a slow bleeding ulcer, which could result in significant amounts of blood loss over time. Nausea and vomiting may be present as a result of the ulcer, especially if it is a gastric ulcer. This does not indicate an immediate life-threatening complication.
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A client is admitted with suspected acute pancreatitis. Which lab finding confirms the diagnosis?
- A. Blood glucose of 260 mg/dL
- B. White cell count of 21,000 cu/mm
- C. Platelet count of 250,000 cu/mm
- D. Serum amylase level of 600 units/dL
Correct Answer: D
Rationale: Elevated serum amylase (typically >3 times normal) is a key diagnostic marker for acute pancreatitis due to pancreatic enzyme leakage. The other findings are nonspecific or normal.
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
- A. Assess the client's respirations
- B. Notify the physician
- C. Auscultate fetal heart rate
- D. Transfer to delivery suite
Correct Answer: C
Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. A 3+ patellar tendon reflex
- B. Respirations of 12 breaths/min
- C. Urine output of 40 mL/hr
- D. A 2+ proteinuria value
Correct Answer: B
Rationale: MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing.
The client with a history of epilepsy is prescribed valproic acid (Depakote). Which laboratory test should the nurse monitor?
- A. Liver function tests
- B. Renal function tests
- C. Complete blood count
- D. Electrolytes
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, so liver function tests (e.g., AST, ALT) are monitored regularly. Renal function, blood counts, and electrolytes are less commonly affected.
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Call the physician to request a psychological consultation for the client
- C. Turn on the television to distract the client's attention from his amputated leg
- D. Give the client his order of Demerol 50 mg IM prn
Correct Answer: D
Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.