Nokea
The client recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?” Which response by the nurse is most accurate?
- A. “As soon as you start to feel hungry you can begin eating.”
- B. “When I hear that your bowel sounds are active and you are passing flatus.”
- C. “When your pain is controlled and your serum lipase level has decreased.”
- D. “You will be NPO for at least more 2 weeks; oral intake stimulates the pancreas.”
Correct Answer: C
Rationale: A. Regaining appetite is a positive sign, but it must be accompanied by a decrease in pain before the client is allowed to take food orally. B. Intestinal peristalsis may be slowed due to inflammation associated with acute pancreatitis, but the return of bowel sounds and flatus is not used to determine when to begin oral intake. C. This response is correct. Once pain is controlled and the serum enzyme levels begin to decrease, the client can begin oral intake. These are signs that the pancreas is healing. D. There is no specific time limit for being NPO.
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The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
- A. Notify the surgeon immediately.
- B. Instruct the client to splint the incision.
- C. Assess the abdominal wound incision.
- D. Administer pain medication intravenously.
Correct Answer: C
Rationale: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
- A. When was your last bowel movement?
- B. Did you have a high-fat meal last night?
- C. Can you describe the type of pain?
- D. Have you been experiencing any gas?
Correct Answer: C
Rationale: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
The nurse is assessing a client who may have a hiatal hernia. What symptom is the client most likely to report?
- A. Projectile vomiting
- B. Crampy lower abdominal pain
- C. Burning substernal pain
- D. Bloody diarrhea
Correct Answer: C
Rationale: Burning substernal pain, often mistaken for heartburn, is a hallmark symptom of hiatal hernia due to acid reflux.
The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering?
- A. Administer total parenteral nutrition.
- B. Maintain NPO and nasogastric tube.
- C. Maintain on a high-fiber diet and increase fluids.
- D. Obtain consent for abdominal surgery.
Correct Answer: B
Rationale: NPO status and an NG tube rest the bowel, reducing inflammation in acute diverticulitis. TPN is rare, high-fiber diets are for stable diverticulosis, and surgery is reserved for complications.