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The client is admitted to a medical unit. The client’s medication list includes rifaximin, lactulose, and propranolol. Which assessment should be the nurse’s priority based on the client’s medication list?
- A. Assess the client for a history of PUD.
- B. Assess the client for abdominal pain.
- C. Place the client on airborne precautions.
- D. Assess neurological status and abdominal girth.
Correct Answer: D
Rationale: A. Antibiotics and acid-reducing medications are expected with the treatment of PUD, but propranolol (Inderal) would not be expected. Although these medications may cue the nurse to further explore a history of PUD, this is not the most likely conclusion. B. There is no indication that the client has abdominal pain, and there isn’t an analgesic on the medication list. C. There is no indication that the client has an infectious condition necessitating airborne precautions. D. All medications listed are used to treat liver cirrhosis and its complications of portal hypertension and hepatic encephalopathy. The antibiotic rifaximin (Xifaxan) and the laxative lactulose (Cephulac) are used for treating hepatic encephalopathy. Thus, assessing the client’s neurological status and measuring abdominal girth are most important.
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While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
The client asks how he contracted hepatitis A. He reports all of the following. Which one is most likely related to hepatitis A?
- A. He ate home-canned corn.
- B. He ate oysters his roommate brought home from a fishing trip.
- C. He stepped on a nail two weeks ago.
- D. He donated blood two weeks before he got sick.
Correct Answer: B
Rationale: Hepatitis A is transmitted via the fecal-oral route, often through contaminated food like oysters. Oysters from unsafe waters are a common source.
The clinic nurse is returning client calls. Which client should the nurse call first?
- A. The 39-year-old client complaining of headache pain with a 3 on the pain scale.
- B. The 45-year-old client who needs a prescription refill for warfarin.
- C. The 54-year-old client diagnosed with diabetes type 1 who has been vomiting.
- D. The 60-year-old client who cannot afford to buy food and needs assistance.
Correct Answer: C
Rationale: Vomiting in a type 1 diabetic risks diabetic ketoacidosis, a medical emergency, requiring immediate attention. Headache, warfarin refill, and food insecurity are less urgent.
The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?
- A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour
- B. Initiate nasojejunal enteral feedings with a low-fat formula
- C. Imipenem-cilastatin 500 mg IV every 6 hours
- D. Up to chair for meals and ambulate four times daily
- E. Position left side-lying with head of bed elevated 30 degrees
- F. Insert a urinary catheter; monitor urine output every 2 hours
Correct Answer: A, B, C, F
Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.
The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?
- A. Start auscultating to the left of the umbilicus.
- B. Turn off the NG suction before auscultation.
- C. Use the bell of the stethoscope for auscultation.
- D. Empty the drainage canister before auscultation.
Correct Answer: B
Rationale: A. When the client has hypoactive bowel sounds, which would be expected in a postsurgical client, the nurse should begin listening over the ileocecal valve in the right lower abdominal quadrant rather than to the left of the umbilicus. The ileocecal valve normally is a very active area. B. When listening for bowel sounds on the client who has an NG tube to suction, the nurse should turn off the suction during auscultation to prevent mistaking the suction sound for bowel sounds. C. The diaphragm of the stethoscope should be utilized for bowel sounds. The bell of the stethoscope should be utilized for abdominal vascular sounds, such as bruits. D. There is no reason to empty the canister before auscultation.