Nokea
The client presents with a complete blockage of the large intestine from a tumor. Which healthcare provider's order would the nurse question?
- A. Obtain consent for a colonoscopy and biopsy.
- B. Start an IV of 0.9% saline at 125 mL/hr.
- C. Administer 3 liters of GoLYTELY.
- D. Give tap water enemas until it is clear.
Correct Answer: C
Rationale: GoLYTELY, a bowel prep, is contraindicated in complete bowel obstruction, as it could worsen the condition or cause perforation. Colonoscopy, IV fluids, and enemas (if cautious) may be appropriate depending on the clinical plan.
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During a clinic visit the client provides all of the following health history information. Which client statement should be most concerning to the nurse because it could describe a symptom of esophageal cancer?
- A. “I have been having a lot of indigestion lately.”
- B. “When I eat meat, it seems to get stuck halfway down.”
- C. “I have been waking up at night lately with chest pain.”
- D. “I gained weight, even though I have not changed my diet.”
Correct Answer: B
Rationale: A. Indigestion is not a symptom of esophageal cancer. B. Progressive dysphagia is the most common symptom associated with esophageal cancer, and it is initially experienced when eating meat. It is often described as a feeling that food is not passing. C. Chest pain is not a symptom of esophageal cancer. D. Weight loss rather than gain is a symptom of esophageal cancer.
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.
Which disease is the client diagnosed with GERD at greater risk for developing?
- A. Hiatal hernia.
- B. Gastroenteritis.
- C. Esophageal cancer.
- D. Gastric cancer.
Correct Answer: C
Rationale: Chronic GERD increases the risk of esophageal cancer, particularly adenocarcinoma, due to prolonged acid exposure causing Barrett's esophagus, a precancerous condition. Hiatal hernia is a risk factor for GERD, not a consequence, and gastroenteritis and gastric cancer are less directly linked.
The nurse assesses the client previously diagnosed as having an inguinal hernia. The nurse considers that the client’s hernia may be strangulated when which assessment findings are noted?
- A. Abdominal distention
- B. Dyspnea with exertion
- C. Severe abdominal pain
- D. No stool for the past week
- E. Hyperactive bowel sounds
Correct Answer: A, C, D
Rationale: Abdominal distention occurs because the bowel is obstructed when the hernia is strangulated. B. Dyspnea with exertion is not associated with strangulation of an inguinal hernia. C. Lack of blood supply from strangulation causes severe abdominal pain. D. A bowel obstruction prevents the passage of stool. E. Bowel sounds with strangulation and bowel obstruction would be hypoactive or absent, not hyperactive.
The dietitian and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing is not an issue?
- A. Cheeseburger and milk shake.
- B. Canned peaches and a sandwich on whole-wheat bread.
- C. Mashed potatoes and mechanically ground red meat.
- D. Biscuits and gravy with bacon.
Correct Answer: C
Rationale: Mashed potatoes and ground meat are soft, low-fiber, and digestible, suitable for immobile clients to prevent constipation. Burgers, whole-wheat, and fatty foods are harder to digest.