Nokea
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
You may also like to solve these questions
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?
- A. Stone fragments are collected when straining the client's urine.
- B. Client denies urinary frequency, urgency, or dysuria.
- C. Urine is pale pink with no observable blood clots.
- D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A
Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.