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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 who may have a hiatal hernia. What symptom is the client most likely to report?
- A. Projectile vomiting
- B. Crampy lower abdominal pain
- C. Burning substernal pain
- D. Bloody diarrhea
Correct Answer: C
Rationale: Burning substernal pain, often mistaken for heartburn, is a hallmark symptom of hiatal hernia due to acid reflux.
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 charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.