Nokea
The client being treated for esophageal varices has a Sengstaken-Blakemore tube inserted to control the bleeding. The most important assessment is for the nurse to:
- A. Check that the hemostat is on the bedside
- B. Monitor IV fluids for the shift
- C. Regularly assess respiratory status
- D. Check that the balloon is deflated on a regular basis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based on this diagnosis?
- A. Spider angiomas
- B. Fatigue
- C. Pale urine
- D. Weight gain
Correct Answer: B
Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis.
The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy?
- A. The cimetidine (Tagamet) will cause me to produce less stomach acid.
- B. Sucralfate (Carafate) will change the fluid in my stomach.
- C. Antacids will coat my stomach.
- D. Omeprazole (Prilosec) will coat the ulcer and help it heal.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with GERD complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?
- A. Development of laryngeal cancer
- B. Irritation of the esophagus
- C. Esophageal scar tissue formation
- D. Aspiration of gastric contents
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following symptoms best describes Murphy's sign?
- A. Periumbilical ecchymosis exists
- B. On deep palpation and release, pain is elicited
- C. On deep inspiration, pain is elicited and breathing stops
- D. Abdominal muscles are tightened in anticipation of palpation
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?
- A. Inspect skin around the T tube daily for irritation.
- B. Irrigate the T tube every 4 hours to maintain patency.
- C. Maintain the client in a supine position while the T tube is in place.
- D. Keep the T tube clamped except during mealtimes.
Correct Answer: A
Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.