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An older client has gastric cancer and is scheduled to have a partial gastrectomy. The family does not want the client to know the diagnosis. What action by the nurse is best?
- A. Ask the family why they feel this way.
- B. Assess family concerns and fears.
- C. Refuse to comply with the family wishes.
- D. Tell the family that such secrets cannot be kept.
Correct Answer: B
Rationale: The nurse should use open-ended questions and statements to fully assess the family's concerns and fears. Asking why questions often puts people on the defensive and is considered a barrier to therapeutic communication. Refusing to comply or stating that secrets cannot be kept may set up an adversarial relationship.
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A nurse working with a client who has possible gastritis assesses the client's gastrointestinal system. Which findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.)
- A. Anorexia
- B. Dyspepsia
- C. Intolerance of fatty foods
- D. Pernicious anemia
- E. Nausea and vomiting
Correct Answer: C,D
Rationale: Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.
A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.)
- A. Ask a second nurse to double-check the blood.
- B. Prime the IV tubing with normal saline.
- C. Prime the IV tubing with dextrose in water.
- D. Take and record a set of vital signs.
- E. Teach the client about reaction manifestations.
Correct Answer: A,B,D,E
Rationale: Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identification), primes the IV tubing with normal saline, takes and records a set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On physician and the client is substance and rapid. What action takes priority?
- A. Administer the prescribed pain medication.
- B. Notify the health care provider immediately.
- C. Prepare all four abdominal quadrants.
- D. Take and document a set of vital signs.
Correct Answer: B
Rationale: This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse should not persens the abdomen or give pain medication since the client may need to sign consent for surgery.
A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright red blood. Which action should the nurse take first?
- A. Assist the client back to bed.
- B. Notify the provider immediately.
- C. Put on a pair of gloves.
- D. Take a set of vital signs.
Correct Answer: C
Rationale: All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid communication with blood or body fluids.
A client is being taught about drug therapy for Helicobacter pylori infection. What assessment by the nurse is appropriate?
- A. Alcohol intake of 1 to 2 drinks per week
- B. Family history of H. pylori infection
- C. Former smoker still using nicotine patches
- D. Willingness to adhere to drug therapy
Correct Answer: D
Rationale: Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for clients to remain adherent. The nurse should assess the client's willingness and ability to follow the regimen. The other assessment findings are not as critical.