Nokea
A nurse is assessing a client who is post-op day #3 after an abdominal hernia repair. After a bout of harsh coughing, the client states, 'it feels like something gave way.' The nurse assesses his abdomen and notes an evisceration from the surgical site. What is the next action of the nurse?
- A. Turn the client on his side
- B. Push the abdominal contents back inside the wound using sterile gloves
- C. Ask the client to take a breath and hold it
- D. Cover the intestine with sterile saline dressings
Correct Answer: D
Rationale: A wound evisceration occurs when the edges of an abdominal wound separate, allowing the coils of the intestine to protrude outside of the body. The nurse should notify the physician at once if this occurs. While waiting for treatment, the nurse should cover the intestines with sterile gauze soaked in saline. Turning the client on his side or asking the client to take a breath and hold it are not appropriate actions in this situation. Pushing the abdominal contents back inside the wound using sterile gloves can lead to infection and is not within the nurse's scope of practice.
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Which of the following conditions most commonly causes acute glomerulonephritis?
- A. A congenital condition leading to renal dysfunction.
- B. Prior infection with group A Streptococcus within the past 10-14 days.
- C. Viral infection of the glomeruli.
- D. Nephrotic syndrome.
Correct Answer: B
Rationale: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.
A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?
- A. I can clean the skin around the ostomy site with soap and water when I change the bag.
- B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
- C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
- D. I should change the bag when it is one-third to one-fourth full.
Correct Answer: C
Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.
A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.
A 24-year-old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Based on the presenting signs and symptoms, which of the following would you most likely suspect?
- A. Diverticulosis
- B. Hypercalcemia
- C. Hypocalcemia
- D. Irritable bowel syndrome
Correct Answer: B
Rationale: The correct answer is Hypercalcemia. In this case, the patient's history of myeloma, constipation, intense abdominal pain, and polyuria suggests hypercalcemia. Elevated calcium levels can lead to polyuria, severe abdominal pain, and confusion. Diverticulosis (Choice A), characterized by small pouches in the colon wall, typically does not present with confusion and polyuria. Hypocalcemia (Choice C) is unlikely given the symptoms described. Irritable bowel syndrome (Choice D) does not typically cause confusion and polyuria as seen in hypercalcemia.
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
- A. Bulging anterior fontanel
- B. Repeated vomiting
- C. Signs of sleepiness at 10 PM
- D. Inability to read short words from a distance of 18 inches
Correct Answer: B
Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.