Nokea
The client is admitted to the medical unit with a diagnosis of acute diverticulitis. Which healthcare provider's order should the nurse question?
- A. Insert a nasogastric tube.
- B. Start an IV with D5W at 125 mL/hr.
- C. Put the client on a clear liquid diet.
- D. Place the client on bedrest with bathroom privileges.
Correct Answer: A
Rationale: An NG tube is not routinely needed for acute diverticulitis unless there is vomiting or obstruction, which is not indicated. IV fluids, clear liquids, and bedrest are standard to rest the bowel and manage inflammation.
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A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
- A. An antacid
- B. A laxative
- C. A muscle relaxant
- D. A sedative
Correct Answer: B
Rationale: Barium is constipating, and a laxative is typically ordered to prevent bowel obstruction post-barium enema.
The client diagnosed with end-stage renal failure and ascites is scheduled for a paracentesis. Which client teaching should the nurse discuss with the client?
- A. Explain the procedure will be done in the operating room.
- B. Instruct the client a Foley catheter will have to be inserted.
- C. Tell the client vital signs will be taken frequently after the procedure.
- D. Provide instructions on holding the breath when the HCP inserts the catheter.
Correct Answer: C
Rationale: Frequent vital sign monitoring post-paracentesis detects complications like hypotension or bleeding. Paracentesis is typically bedside, Foley catheters are unnecessary, and breath-holding is not standard.
The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?
- A. “I have been experiencing headaches immediately after eating.”
- B. “Lately, I wake up at night with a burning feeling in my chest.”
- C. “I have been waking up at night sweating and wet all over.”
- D. “Immediately after eating I feel sleepy and want to go to bed.”
Correct Answer: B
Rationale: A. Headaches are a symptom not related to GERD. B. Heartburn, which is described as a burning, tight sensation in the lower sternum, is the most common symptom of GERD. It will often wake the client from sleep. C. Night sweats are a symptom not related to GERD. D. Postprandial sleepiness is a symptom not related to GERD.
Which blood test results would confirm a diagnosis of appendicitis?
- A. WBC of 13,000
- B. RBC of 4.5 million
- C. Platelet count of 300,000
- D. Positive heterophil antibody test
Correct Answer: A
Rationale: An elevated WBC count (e.g., 13,000) indicates inflammation, supporting an appendicitis diagnosis. Normal RBC and platelet counts are not specific, and a heterophil antibody test is for infectious mononucleosis.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.