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The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
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The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?
- A. Steady, aching pain in one specific area.
- B. Sharp back pain radiating to the flank.
- C. Sharp pain increases with deep breaths.
- D. Intermittent colicky pain near the umbilicus.
Correct Answer: D
Rationale: Intermittent colicky pain near the umbilicus is characteristic of bowel obstruction due to peristalsis against the blockage. Steady pain, back pain, and pain with breathing suggest other conditions.
The client is prescribed infliximab 5 mg/kg every 8 weeks for treatment of Crohn’s disease. The client weighs 116 lb. How many milligrams (mg) should the nurse administer? _________ mg (Record your answer rounded to a whole number.)
Correct Answer: 264
Rationale: To calculate the dose: 1. Convert weight to kilograms: 116 lb ÷ 2.2 = 52.727 kg. 2. Calculate dose: 5 mg/kg × 52.727 kg = 263.635 mg. 3. Round to a whole number: 264 mg.
The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.
The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase?
- A. Clay-colored stools and jaundice.
- B. Normal appetite and pruritus.
- C. Being afebrile and left upper quadrant pain.
- D. Complaints of fatigue and diarrhea.
Correct Answer: D
Rationale: The preicteric phase of hepatitis involves nonspecific symptoms like fatigue and diarrhea before jaundice appears. Clay-colored stools, jaundice, and pruritus occur in the icteric phase.
The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.