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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.
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The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.
The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.
The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase?
- A. Clay-colored stools and jaundice.
- B. Normal appetite and pruritus.
- C. Being afebrile and left upper quadrant pain.
- D. Complaints of fatigue and diarrhea.
Correct Answer: D
Rationale: The preicteric phase of hepatitis involves nonspecific symptoms like fatigue and diarrhea before jaundice appears. Clay-colored stools, jaundice, and pruritus occur in the icteric phase.
The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease (IBD). Which intervention should the nurse discuss with the client?
- A. Take this medication on an empty stomach.
- B. Notify the HCP if experiencing a moon face.
- C. Take the steroid medication as prescribed.
- D. Notify the HCP if the blood glucose is over 160.
Correct Answer: D
Rationale: Prednisone can elevate blood glucose levels, particularly in diabetic patients, so monitoring and reporting elevated glucose (>160 mg/dL) is critical to prevent hyperglycemia complications. Moon face is a side effect but less urgent, and steroids should be taken with food to reduce gastric irritation.
The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?
- A. Administer the polyethylene glycol electrolyte lavage solution.
- B. Explain to the client why this morning's breakfast is withheld.
- C. Start an intravenous site with 0.9% normal saline fluid.
- D. Administer a cleansing enema until the return is clear.
Correct Answer: D
Rationale: Administering a cleansing enema is within the UAP’s scope with training. Administering solutions, explaining procedures, and starting IVs require RN skills.