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A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse complete first?
- A. Inspection of oral mucosa
- B. Review of recent dietary intake
- C. Heart rate and rhythm
- D. Percussion of abdomen
Correct Answer: C
Rationale: Severe diarrhea can lead to hypovolemia and electrolyte imbalances, such as low potassium or magnesium, which may cause dysrhythmias. Assessing heart rate and rhythm is the priority to detect potential cardiac complications. Oral mucosa inspection, dietary intake review, and abdominal percussion are important but lower priority.
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A nurse cares for a client who has a Giardia infection. Which medication should the nurse anticipate being prescribed for this client?
- A. Metronidazole (Flagyl)
- B. Ciprofloxacin (Cipro)
- C. Sulfasalazine (Azulfidine)
- D. Ceftriaxone (Rocephin)
Correct Answer: A
Rationale: Metronidazole is the drug of choice for Giardia, a parasitic infection. Ciprofloxacin and ceftriaxone treat bacterial infections, and sulfasalazine is used for ulcerative colitis or Crohn's disease, not Giardia.
A nurse plans care for a client with Crohn's disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this client's plan of care?
- A. Low-fiber diet
- B. Skin protection
- C. Antibiotic administration
- D. Blood glucose monitoring
Correct Answer: B
Rationale: A heavily draining fistula releases caustic intestinal fluids that can cause skin breakdown or infections. Skin protection is the priority to prevent complications. Nutrition, antibiotics, and glucose monitoring are important but secondary.
A nurse reviews the chart of a client who has Crohn's disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions?
- A. Serum potassium of 2.6 mEq/L
- B. Client ate 25% of breakfast meal
- C. White blood cell count of 8200/mm³
- D. Client's weight decreased by 3 pounds
Correct Answer: A
Rationale: A serum potassium level of 2.6 mEq/L is critically low and can lead to serious dysrhythmias, requiring urgent intervention. A normal white blood cell count (8200/mm³) does not warrant immediate action. Reduced meal intake and weight loss are concerning but less urgent than hypokalemia.
A nurse cares for a client who is prescribed 5 mg/kg of infliximab (Remicade) intravenously. The client weighs 110 lbs and the pharmacy supplies infliximab 100 mg/10 mL solution. How many milliliters should the nurse administer to this client? (Record your answer using a whole number)
- A. 20 mL
- B. 25 mL
- C. 30 mL
- D. 35 mL
Correct Answer: B
Rationale: The client weighs 110 lbs (50 kg). The dose is 5 mg/kg, so 5 mg/kg ? 50 kg = 250 mg. The pharmacy supplies 100 mg/10 mL, so 250 mg ÷ 100 mg/10 mL = 25 mL.
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?
- A. A severe steady right lower quadrant pain.
- B. Abdominal pain associated with nausea and vomiting
- C. Marked peristalsis and hyperactive bowel sounds.
- D. Abdominal pain that increases with knee flexion
Correct Answer: A
Rationale: Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Nausea and vomiting typically indicate gastroenteritis if they occur first. Marked peristalsis and hyperactive bowel sounds are not typical of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.