Nokea
The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?
- A. The client has a soft, nontender abdomen.
- B. The client has a loose, watery stool.
- C. The client has hyperactive bowel sounds.
- D. The client's pulse is 104 and BP is 98/60.
Correct Answer: D
Rationale: Tachycardia (pulse 104) and low BP (98/60) suggest possible bleeding or hypovolemia post-colonoscopy, requiring immediate intervention. A soft abdomen, watery stool, and hyperactive bowel sounds are expected.
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The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?
- A. Auscultate the client's bowel sounds in all four quadrants.
- B. Palpate the abdominal area for tenderness.
- C. Percuss the abdominal borders to identify organs.
- D. Assess the tender area progressing to nontender.
Correct Answer: B
Rationale: Palpating for tenderness helps identify epigastric pain, a key symptom of peptic ulcer disease, and guides further assessment. Auscultation, percussion, and specific tender-to-nontender assessment are secondary in this context.
The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next?
- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.
The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?
- A. Assess the abdomen for a tympanic wave.
- B. Monitor the client's blood pressure.
- C. Percuss the liver for size and location.
- D. Weigh the client twice each week.
Correct Answer: B
Rationale: Monitoring blood pressure detects complications of portal hypertension, like variceal bleeding. Tympanic wave is incorrect, liver percussion is less urgent, and weight checks are secondary.
The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.