Nokea
A nurse is assigned to care for a client with liver dysfunction and ascites and is ordered to measure the client's abdominal girth daily. To ensure accuracy, the nurse should utilize which landmark?
- A. Xiphoid process
- B. Umbilicus
- C. Iliac crest
- D. Symphysis pubis
Correct Answer: B
Rationale: The umbilicus (B) is a consistent anatomical landmark for measuring abdominal girth in ascites, ensuring accurate and reproducible measurements.
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The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply.
- A. I will not be able to eat or drink anything for six to eight hours before this procedure.
- B. I will have to do a bowel prep before this procedure.
- C. Someone will have to drive me home after this procedure.
- D. I should notify my physician if I have abdominal pain and distention for one or two days following this procedure.
- E. I can expect to have white stools one to two days following this procedure.
Correct Answer: B,D,E
Rationale: Bowel prep (B) is not typically required for ERCP. Persistent pain and distention (D) post-ERCP require immediate notification, not delayed. White stools (E) are not expected post-ERCP. Fasting (A) and needing a driver (C) are correct.
The following scenario applies to the next 1 items
The nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
• Oral temperature 101° F (38.3°C)
• Pulse 90/minute
• Respirations 18/minute
• Blood Pressure 110/66 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
• White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
• Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
• BUN 26 mg/dL (10-20 mg/dL)
• Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
- A. Oral temperature 101°F (38.3°C)
- B. White blood cell count, 11,500 mm³
- C. Creatinine, 0.9 mg/dL
- D. Nausea and vomiting
- E. Potassium 3.3 mEq/L
- F. BUN 26 mg/dL
- G. Reports of pain increasing while coughing
Correct Answer: A,D
Rationale: Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.
You are caring for a client who is in the burn unit with severe burns. Since this is your first client contact with this person, you introduce yourself and tell the client that they will be taken care of by you for this shift. The client greets you and states, 'Why am I getting this stuff that is hanging up here?' as they are pointing to the ordered total parenteral infusion. You should:
- A. Respond to the client stating, 'I don't think you should be getting this. I am going to call your doctor.'
- B. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired as the result of your burns'.
- C. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired because you aren't eating enough.'
- D. Respond to the client stating, 'I don't think you should be getting this. I am going to turn it off now.'
Correct Answer: B
Rationale: TPN (B) is used in burn patients to meet high nutritional demands when oral intake is insufficient due to metabolic stress from burns, not just lack of eating (C). Options A and D are inappropriate as they suggest stopping or questioning a valid treatment.
The nurse has provided medication instruction to a client prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication one hour after meals.
- B. I will remain upright for 30 minutes after taking this medicine.
- C. This medication will help with my peptic ulcer disease.
- D. I know this medication works when my nausea and vomiting are gone.
- E. I may dissolve this medication in warm water.
Correct Answer: A,D,E
Rationale: Sucralfate is taken 1 hour before meals, not after; it treats ulcers but does not primarily relieve nausea/vomiting; and it should not be dissolved in water. Remaining upright and ulcer treatment are correct.
The nurse is reviewing gastrointestinal assessment with a group of student nurses. It would be correct if the student identifies which of the following would cause hyperactive bowel sounds?
- A. Paralytic ileus
- B. Gastroenteritis
- C. Late bowel obstruction
- D. Peritonitis
Correct Answer: B
Rationale: Gastroenteritis (B) causes hyperactive bowel sounds due to increased intestinal motility from inflammation or infection. Paralytic ileus (A), late bowel obstruction (C), and peritonitis (D) typically cause hypoactive or absent bowel sounds.