Nokea
The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
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The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
- A. No bowel movement.
- B. Oxygen saturation 96%.
- C. Vital signs within normal baseline.
- D. Intact gag reflex.
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
While performing a home visit, the nurse observes that the client’s head of the bed is raised on 6-in. blocks. The nurse should question the client for a history of which conditions?
- A. Hiatal hernia
- B. Dumping syndrome
- C. Crohn’s disease
- D. Gastroesophageal reflux disease
- E. Gastritis
Correct Answer: A, D
Rationale: Clients with a hiatal hernia are encouraged to sleep with the HOB elevated on 4- to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. B. Dumping syndrome occurs after surgery when the stomach no longer has control over the amount of chime that enters the small intestine. Clients are encouraged to lie flat after a meal. C. Crohn’s disease is an inflammatory disease of the bowel. Positioning interventions do not decrease symptoms. D. Clients with GERD are encouraged to sleep with the HOB elevated on 4— to 6-in. blocks to reduce intraabdominal pressure and to foster esophageal emptying. E. Gastritis is inflammation of the gastric mucosa. Positioning interventions do not decrease symptoms.
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.
The nurse is assessing the client diagnosed with chronic gastritis. Which symptom(s) support this diagnosis?
- A. Rapid onset of midsternal discomfort.
- B. Epigastric pain relieved by eating food.
- C. Dyspepsia and hematemesis.
- D. Nausea and projectile vomiting.
Correct Answer: C
Rationale: Dyspepsia (indigestion) and hematemesis (vomiting blood) are symptoms of chronic gastritis due to mucosal irritation. Midsternal pain, pain relief with food, and projectile vomiting are less typical.
The client had Billroth II surgery 24 hours ago. The client’s son approaches the nurse in the hallway and asks for information regarding his father’s condition. The wife is listed as the designated contact person. Which nurse response is best?
- A. “What has the surgeon told you about your father’s condition?”
- B. “Let’s both go into your father’s room and ask him how he feels.”
- C. “Let’s go to a more private place to discuss your father’s condition.”
- D. “Let’s review your father’s medical record information together.”
Correct Answer: B
Rationale: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client’s room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.