Nokea
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.
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A nurse is preparing to administer pantoprazole (Protonix) intravenously. What actions by the nurse are best? (Select all that apply.)
- A. Administer the drug through a separate IV line.
- B. Infuse pantoprazole using an IV pump.
- C. Keep the drug in its original brown bag.
- D. Take vital signs frequently during infusion.
- E. Use an in-line IV filter when infusing.
Correct Answer: A,B,E
Rationale: When infusing pantoprazole, use a separate IV line, a pump, and an in-line filter. A brown wrapper and frequent vital signs are not needed.
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 client has a recurrence of gastric cancer and is in the gastrointestinal clinic crying. What response by the nurse is most appropriate?
- A. Do you have family or friends for support?
- B. I'd like to know what you are feeling now.
- C. Well, we knew this would probably happen.
- D. Would you like me to refer you to hospice?
Correct Answer: B
Rationale: The nurse assesses the client's emotional state with open-ended questions and statements and shows a willingness to listen to the client's concerns. Asking about support people is very limited in nature, and yes-or-no questions are not therapeutic. Saying that this was expected dismisses the client's concerns. The client may or may not be ready to hear about hospice, and this is another limited, yes-or-no question.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is appropriate?
- A. Alcohol intake of 1 to 2 drinks per week
- B. Family history of H. pylori infection
- C. Former smoker still using nicotine patches
- D. Willingness to adhere to drug therapy
Correct Answer: D
Rationale: Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.
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.