Nokea
The client is admitted with upper right-side abdominal pain. The nurse is concerned that the client may have liver cancer when which serum laboratory test results are elevated?
- A. Creatinine and BUN
- B. α-fetoprotein (AFP)
- C. Phosphorus levels
- D. CA-125 levels
Correct Answer: B
Rationale: A. Elevated serum creatinine and BUN are associated with renal problems. B. Serum α-fetoprotein is a major serum protein synthesized by fetal liver cells, by yolk sac cells, and in small amounts by the fetal GI system. Reappearance of AFP in adults signals pathological problems. In 50% to 75% of clients with liver cancer, serum AFP levels are elevated. C. Elevated serum phosphorus is associated with renal and many other diseases and is not specific to liver cancer. D. CA-125 is a tumor marker for ovarian cancer.
You may also like to solve these questions
The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.
The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.
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.
The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care?
- A. Allow any of the client's favorite foods as long as the amount is limited.
- B. Have the client perform eructation exercises several times a day.
- C. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes.
- D. Encourage the client to consume a glass of red wine with one (1) meal a day.
Correct Answer: C
Rationale: Eating small, frequent meals reduces stomach distension, which can trigger reflux, and limiting fluids during meals prevents excessive gastric volume. Favorite foods may include triggers, eructation exercises are not standard, and alcohol like red wine can worsen GERD.