Nokea
Joan is diagnosed with a gastric ulcer. What symptoms would she exhibit?
- A. Epigastric pain worse before meals, pain on awakening, and melena.
- B. Decreased bowel sounds, rigid abdomen, rebound tenderness, and fever.
- C. Boring epigastric pain radiating to back and left shoulder, bluish-gray discoloration of periumbilical area, and ascites.
- D. Epigastric pain that is worse after eating and weight loss.
Correct Answer: A
Rationale: Gastric ulcers typically cause pain before meals and at night.
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A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
- A. chloride.
- B. bicarbonate.
- C. potassium.
- D. sodium.
Correct Answer: C
Rationale: Chloride, bicarbonate, and sodium will need to be monitored, but they are not as important as potassium. Potassium will need to be closely monitored, because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias.
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
A healthcare professional is monitoring a client following a thoracentesis. The healthcare professional should identify which of the following manifestations as a complication and contact the provider immediately?
- A. Serosanguineous drainage from the puncture site
- B. Discomfort at the puncture site
- C. Increased heart rate
- D. Decreased temperature
Correct Answer: C
Rationale: The correct answer is C, increased heart rate, as it indicates a potential complication such as hemorrhage or pneumothorax post-thoracentesis. An increased heart rate can signify hypovolemia or respiratory distress, requiring immediate provider notification. Serosanguineous drainage (A) is expected initially, discomfort (B) is common, and decreased temperature (D) is not typically a complication post-thoracentesis.
Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.
Mary, who is diagnosed with osteomyelitis, may not heal properly unless she has
- A. Debridement and drainage of the area.
- B. Immobilization of the area.
- C. Ice packs alternating with moist heat, applied externally.
- D. Internal fixation device inserted.
Correct Answer: A
Rationale: Debridement and drainage are necessary to remove infected tissue and promote healing.