Nokea
The charge nurse has just received the shift report. Which client should the nurse see first?
- A. The client diagnosed with Crohn's disease who had two (2) semiformed stools on the previous shift.
- B. The elderly client admitted from another facility who is complaining of constipation.
- C. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor.
- D. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.
Correct Answer: C
Rationale: The AIDS client with diarrhea and elastic turgor may still be dehydrated, requiring immediate assessment for electrolyte imbalances. Crohn’s stools, constipation, and hemorrhoid bleeding are less urgent.
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The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?
- A. Mark the drainage on the dressing with the time and date.
- B. Change the dressing immediately using sterile technique.
- C. Notify the health-care provider immediately.
- D. Reinforce the dressing with a sterile gauze pad.
Correct Answer: C
Rationale: Dark reddish brown drainage one day post-surgery suggests possible bleeding or dehiscence, warranting immediate notification of the HCP for evaluation. Marking or reinforcing the dressing delays action, and changing the dressing is secondary.
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?
- A. The UAP is assisting the client to take a hot, soapy shower.
- B. The UAP applies an emollient to the client's legs and back.
- C. The UAP puts mittens on both hands of the client.
- D. The UAP pats the client's skin dry with a clean towel.
Correct Answer: A
Rationale: Hot, soapy showers can worsen pruritus by drying the skin, requiring intervention. Emollients, mittens (to prevent scratching), and patting dry are appropriate.
The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first?
- A. Ask the parent about the child's diet.
- B. Assess the child's tissue turgor.
- C. Give the child a sucker if she is good.
- D. Notify the HCP the child is waiting to be seen.
Correct Answer: B
Rationale: Assessing tissue turgor evaluates dehydration, a priority in a toddler with vomiting and diarrhea. Diet history, rewards, and HCP notification follow assessment.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.