Nokea
A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?
- A. Tenderness in the left upper abdomen
- B. Ecchymosis of the extremities
- C. Pale-colored urine
- D. Fatty stools
Correct Answer: D
Rationale: Fatty stools (steatorrhea) occur with common bile duct obstruction because bile cannot reach the intestine to emulsify fats.
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A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?
- A. Bubbling of the water in the water seal chamber with exhalation
- B. Crepitus in the area above and surrounding the insertion site
- C. Movement of the trachea toward the unaffected side
- D. Eyelets are not visible
Correct Answer: B
Rationale: Crepitus indicates subcutaneous emphysema, which requires immediate attention as it suggests air leaking into tissues.
A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over a 24-hour period using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 35
Rationale: Calculation: 840 mL ÷ 24 hours = 35 mL/hr
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.
The client is scheduled to receive 30 grams of lactulose orally every 12 hours. An oral solution containing 5 g/10 mL is available. How many mL should be poured into the medication cup to administer the required dose?
Correct Answer: 60
Rationale: Calculation: (30 g ÷ 5 g) × 10 mL = 60 mL
A nurse is caring for a client who has a pulmonary embolism and has been on a heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?
- A. Both heparin and warfarin work together to dissolve the clots.
- B. Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level.
- C. The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay.
- D. I will call the provider to get a prescription for discontinuing the IV heparin today.
Correct Answer: B
Rationale: Overlap therapy is needed because warfarin has delayed onset (3-5 days) while heparin provides immediate anticoagulation.