Nokea
A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)
- A. Beta-blocking agent
- B. Diuretic
- C. Opioid analgesic
- D. Lactulose
- E. Sedative
Correct Answer: A,B,D
Rationale: Beta-blockers reduce portal pressure, diuretics manage ascites, and lactulose treats hepatic encephalopathy.
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A nurse is caring for a client who has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Occasional bubbling in the water-seal chamber
- B. No reports of pleuritic chest pain
- C. No tidaling in the water-seal chamber
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Absence of tidaling indicates lung re-expansion as intrapleural pressure equalizes.
A nurse is planning care for a client who is receiving enteral feedings through a nasogastric (NG) tube. Which of the following actions should the nurse plan to take first?
- A. Label the feeding bag with the date and time of the start of the feeding.
- B. Aspirate the client's stomach contents.
- C. Hang the feeding bag 30 cm (12 inches) above the client.
- D. Warm the feeding to room temperature.
Correct Answer: B
Rationale: Aspirating the client's stomach contents is the first action the nurse should take to confirm correct placement of the NG tube before administering feeding.
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.
A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?
- A. BUN 8 mg/dL and creatinine 0.7 mg/dL
- B. BUN 45 mg/dL and creatinine 8 mg/dL
- C. BUN 10 mg/dL and creatinine 0.3 mg/dL
- D. BUN 23 mg/dL and creatinine 1.0 mg/dL
Correct Answer: B
Rationale: Elevated BUN and creatinine reflect impaired kidney function in CKD.
The nurse is monitoring a client who just finished a meal for vasomotor manifestations of dumping syndrome. Which of the following findings indicate this occurrence?
- A. Dizziness and pallor
- B. Abdominal cramping and pain
- C. Bradycardia and indigestion
- D. Double vision and chest pain
Correct Answer: A
Rationale: Vasomotor symptoms (dizziness, pallor, diaphoresis) occur from rapid fluid shifts in dumping syndrome.