Nokea
A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. The nurse should monitor the client most closely for which of the following?
- A. Swelling of the abdomen
- B. Bloody diarrhea
- C. Vomiting blood
- D. An elevated temperature and arise in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Vomiting blood. When the esophageal balloon of the Sengstaken-Blakemore tube is deflated, the risk of esophageal variceal bleeding increases. Vomiting blood indicates active bleeding and requires immediate intervention. Swelling of the abdomen (A) is not directly related to deflating the balloon. Bloody diarrhea (B) is not a common complication of deflating the balloon. An elevated temperature and a rise in blood pressure (D) are not typical signs of complications related to the deflation of the esophageal balloon.
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A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site.
A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period.
C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage.
D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
Of the following signs and symptoms of bowel obstruction, which is related primarily to small bowel obstruction rather than large bowel obstruction?
- A. Profuse vomiting.
- B. Cramping abdominal pain.
- C. Abdominal distention.
- D. High-pitched bowel sounds above the obstruction.
Correct Answer: A
Rationale: The correct answer is A: Profuse vomiting. In small bowel obstruction, the vomitus is typically profuse, as the small bowel is narrower and more distensible than the large bowel. This leads to rapid accumulation of gastric contents resulting in frequent vomiting. Cramping abdominal pain (B) can occur in both small and large bowel obstruction. Abdominal distention (C) is a common symptom in both types of obstruction due to the accumulation of gas and fluid. High-pitched bowel sounds above the obstruction (D) are indicative of partial obstruction and can be present in both small and large bowel obstruction.
When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:
- A. Controlling abdominal pain.
- B. Maintaining a regular bowel elimination pattern.
- C. Preventing respiratory complications.
- D. Maintaining a positive, optimistic outlook.
Correct Answer: D
Rationale: The correct answer is D: Maintaining a positive, optimistic outlook. This is because having a positive mindset can help the client cope better with the challenges of extended convalescence. It can improve overall well-being, mental health, and motivation for recovery.
A: Controlling abdominal pain - While abdominal pain may be a symptom of hepatitis A, it is not the most crucial aspect for extended convalescence.
B: Maintaining a regular bowel elimination pattern - While important for overall health, this is not specifically related to complications from hepatitis A.
C: Preventing respiratory complications - While respiratory complications can occur in severe cases of hepatitis A, it is not the most likely difficulty the client will face during extended convalescence.
A client who has had gastrectomy is not producing sufficient intrinsic factor. The nurse interprets that the client has lost the ability to absorb cyanocobalamin (vitamin B12) in the
- A. Stomach.
- B. Small intestine.
- C. Large intestine.
- D. Colon.
Correct Answer: B
Rationale: The correct answer is B: Small intestine. After a gastrectomy, where the stomach is removed or bypassed, intrinsic factor production is reduced, impacting the absorption of vitamin B12. Intrinsic factor is necessary for the absorption of B12 in the small intestine, specifically in the ileum. If vitamin B12 is not absorbed in the small intestine, it can lead to pernicious anemia. Therefore, the small intestine is crucial for the absorption of vitamin B12 in the absence of intrinsic factor. Choices A, C, and D are incorrect as the stomach, large intestine, and colon do not play a significant role in the absorption of vitamin B12.
The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?
- A. Carbohydrate
- B. Protein
- C. Fat
- D. Water-soluble vitamins
Correct Answer: C
Rationale: The correct answer is C: Fat. In chronic pancreatitis, the pancreas struggles to produce digestive enzymes, leading to poor fat digestion. Limiting fat intake can help reduce symptoms like abdominal pain and diarrhea. Carbohydrates and proteins are essential for energy and tissue repair, so limiting them is not ideal. Water-soluble vitamins are generally well-absorbed and do not require restriction in chronic pancreatitis.