Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?
- A. Dyspnea and reduced or absent breath sounds over the right lung
- B. Tachycardia, hypotension, and cool, clammy skin
- C. Fever, rebound tenderness, and abdominal rigidity
- D. Redness, warmth, and drainage at the biopsy site
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?
- A. Initiate continuous enteral feedings
- B. Encourage a high protein, high-calorie diet
- C. Implement total parenteral nutrition
- D. Provide six small meals a day.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, "I know that I have colon cancer, too." Which response is most therapeutic?
- A. I know just how you feel.
- B. You seem upset.
- C. Oh, don't worry about it, everything will be just fine.
- D. Why do you think you have cancer?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?
- A. There is no skin breakdown.
- B. Her appetite improves.
- C. She loses more than 10 lbs.
- D. Stools are less fatty and decreased in frequency.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?
- A. Notify the doctor immediately.
- B. Stop the feeding, and clamp the NG tube.
- C. Discard the 220ml, and clamp the NG tube.
- D. Give a prescribed GI stimulant such as metoclopramide (Reglan).
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patient's diet?
- A. Meats and beans.
- B. Butter and gravies.
- C. Potatoes and pastas.
- D. Cakes and pastries.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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