Nokea
The client has an eviscerated abdominal wound. Which intervention should the nurse implement?
- A. Apply sterile normal saline dressing.
- B. Use sterile gloves to replace protruding parts.
- C. Place the client in reverse Trendelenburg position.
- D. Administer intravenous antibiotic immediately (STAT).
Correct Answer: A
Rationale: Applying a sterile normal saline dressing keeps the eviscerated wound moist and protected until surgical repair. Replacing organs is contraindicated, reverse Trendelenburg is incorrect, and antibiotics are secondary.
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The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?
- A. Bowel sounds auscultated 15 times in one (1) minute.
- B. Belching after eating a heavy and fatty meal late at night.
- C. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.
- D. A decreased frequency of distress located in the epigastric region.
Correct Answer: C
Rationale: A 20 mm Hg drop in systolic BP on positional change suggests orthostatic hypotension, possibly from bleeding, requiring immediate intervention. Normal bowel sounds, belching, and reduced pain are less concerning.
The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.
The nurse assesses a large amount of red drainage on the dressing of a client who is six (6) hours postoperative open cholecystectomy. Which intervention should the nurse implement?
- A. Measure the abdominal girth.
- B. Palpate the lower abdomen for a mass.
- C. Turn client onto side to assess for further drainage.
- D. Remove the dressing to determine the source.
Correct Answer: D
Rationale: Removing the dressing to assess the source of red drainage (e.g., bleeding or dehiscence) is critical for timely intervention. Other actions are secondary to identifying the cause.
Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis?
- A. Assess the skin turgor on the back of the client’s hands.
- B. Monitor the client for orthostatic hypotension.
- C. Record the frequency and characteristics of sputum.
- D. Use Standard Precautions when caring for the client.
- E. Institute safety precautions when ambulating the client.
Correct Answer: A,B,D,E
Rationale: Assessing skin turgor and orthostatic hypotension monitors dehydration, Standard Precautions prevent spread, and safety precautions address weakness in the elderly. Sputum is unrelated to gastroenteritis.
Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
- A. Assess the client's neurological status.
- B. Prepare to administer a loop diuretic.
- C. Check the client's stool for blood.
- D. Assess for an abdominal fluid wave.
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.