Nokea
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
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The charge nurse has just received the shift report. Which client should the nurse see first?
- A. The client diagnosed with Crohn's disease who had two (2) semiformed stools on the previous shift.
- B. The elderly client admitted from another facility who is complaining of constipation.
- C. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor.
- D. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.
Correct Answer: C
Rationale: The AIDS client with diarrhea and elastic turgor may still be dehydrated, requiring immediate assessment for electrolyte imbalances. Crohn’s stools, constipation, and hemorrhoid bleeding are less urgent.
The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first?
- A. Ask the parent about the child's diet.
- B. Assess the child's tissue turgor.
- C. Give the child a sucker if she is good.
- D. Notify the HCP the child is waiting to be seen.
Correct Answer: B
Rationale: Assessing tissue turgor evaluates dehydration, a priority in a toddler with vomiting and diarrhea. Diet history, rewards, and HCP notification follow assessment.
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
- A. Pain related to heartburn from gastric reflux.
- B. Aspiration related to regurgitation of food accumulated in the diverticula.
- C. Constipation related to anatomical changes of the sigmoid colon.
- D. Altered nutrition, less than body requirements related to dysphagia.
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD?
- A. Adult-onset asthma.
- B. Pancreatitis.
- C. Peptic ulcer disease.
- D. Increased gastric emptying.
Correct Answer: A
Rationale: GERD is commonly associated with adult-onset asthma due to acid reflux irritating the airways, leading to bronchospasm. Pancreatitis and peptic ulcer disease are less directly linked, and increased gastric emptying is not a typical comorbidity.