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A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
- A. Heart rate and rhythm
- B. Bowel sounds
- C. Urinary output
- D. Respiratory rate
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.
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A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Pale and bluish stoma
- B. Liquid stool
- C. Ostomy pouch intact
- D. Blood-smeared output
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.
A nurse cares for a client with a new ileostomy. The client states, 'I don't think my friends will accept me with this ostomy.' How should the nurse respond?
- A. Your friends will be happy you are alive.
- B. Tell me more about your concerns.
- C. A therapist can help you resolve your concerns.
- D. With time you will accept your new body.
Correct Answer: B
Rationale: Encouraging the client to express concerns addresses social anxiety and apprehension common with a new ostomy. Minimizing concerns, suggesting a therapist without discussion, or assuming acceptance over time are not therapeutic responses.
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 assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- A. Distended abdomen
- B. Diminished bowel sounds
- C. Bradycardia
- D. Hyperactive bowel sounds
- E. Inability to pass flatus or feces
- F. Tachycardia
Correct Answer: A,B,E,F,G
Rationale: Peritonitis presents with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output due to inflammation and dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.
A nurse assesses a client who is hospitalized for diverticulitis. The client's vital signs are temperature: 99.8°F (37.6°C), heart rate: 100 beats/min, respiratory rate: 18 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take first?
- A. Decrease stimulation and allow the client to rest.
- B. Stay with the client while another nurse calls the provider.
- C. Increase the client's intravenous fluid replacement rate.
- D. Check the client's blood glucose and administer orange juice.
Correct Answer: B
Rationale: The client's vital signs suggest possible hypovolemia or early sepsis due to diverticulitis (elevated heart rate, low blood pressure, and mild fever). Staying with the client and having another nurse contact the provider ensures rapid assessment and intervention. Rest, fluid rate increase, or glucose checks are not the priority without further assessment.