Nokea
The emergency department (ED) nurse reviews the client's triage note. Select the findings in the triage note that require immediate follow-up.
- A. 56-year-old male reports persistent nausea and vomiting that has not improved with prescribed anti-emetic.
- B. He reports being diagnosed with viral gastroenteritis three days ago by his physician.
- C. He states that his n/v has gotten so bad that he cannot hold down food or fluids.
- D. On assessment, the client is lethargic and oriented. Unsteady gait.
- E. He reports that he can take his prescribed medications with sips of water.
- F. On assessment, the client is lethargic and oriented. Unsteady gait.
- G. Vital signs: T 99°F (37°C), P 108, RR 18, BP 132/77, pulse oximetry reading 97% on room air.
Correct Answer: A,C,D,F
Rationale: Persistent nausea/vomiting (A, C), lethargy, and unsteady gait (D, F) suggest dehydration or electrolyte imbalances requiring immediate follow-up.
You may also like to solve these questions
The nurse is developing a teaching plan for a client with post-gastrectomy dumping syndrome. Which of the following statements should the nurse make to the client?
- A. Take small sips of water during meals to soften the food for easier digestion.
- B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery.
- C. Plan rest periods of 10 minutes after every meal.
- D. Meals should consist of dry foods with low carbohydrates, moderate fat, and high protein content.
Correct Answer: D
Rationale: Dry, low-carbohydrate, moderate-fat, high-protein meals (D) slow gastric emptying, reducing dumping syndrome symptoms. Sips during meals (A), expecting resolution in 4-6 weeks (B), or short rest periods (C) are incorrect.
The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?
- A. Administer analgesics to control pain
- B. Monitor for signs of infection
- C. Monitor for signs of hypovolemia
- D. Ensure that the ascitic fluid is sent to the lab for analysis
Correct Answer: C
Rationale: Monitoring for hypovolemia (C) is critical after paracentesis due to the risk of fluid shifts from removing large volumes of ascitic fluid.
The following scenario applies to the next 1 items
The nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
• Oral temperature 101° F (38.3°C)
• Pulse 90/minute
• Respirations 18/minute
• Blood Pressure 110/66 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
• White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
• Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
• BUN 26 mg/dL (10-20 mg/dL)
• Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
- A. Oral temperature 101°F (38.3°C)
- B. White blood cell count, 11,500 mm³
- C. Creatinine, 0.9 mg/dL
- D. Nausea and vomiting
- E. Potassium 3.3 mEq/L
- F. BUN 26 mg/dL
- G. Reports of pain increasing while coughing
Correct Answer: A,D
Rationale: Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer? Select all that apply.
- A. Ulcerative colitis
- B. Body Mass Index (BMI) of 21
- C. Human Immunodeficiency Virus (HIV) infection
- D. Low-fiber diet
- E. Excessive alcohol consumption
- F. African-American ethnicity
Correct Answer: A,D,E,F
Rationale: Ulcerative colitis (A), low-fiber diet (D), excessive alcohol (E), and African-American ethnicity (F) are risk factors for colorectal cancer. Normal BMI (B) and HIV (C) are not directly linked.
The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply.
- A. I will not be able to eat or drink anything for six to eight hours before this procedure.
- B. I will have to do a bowel prep before this procedure.
- C. Someone will have to drive me home after this procedure.
- D. I should notify my physician if I have abdominal pain and distention for one or two days following this procedure.
- E. I can expect to have white stools one to two days following this procedure.
Correct Answer: B,D,E
Rationale: Bowel prep (B) is not typically required for ERCP. Persistent pain and distention (D) post-ERCP require immediate notification, not delayed. White stools (E) are not expected post-ERCP. Fasting (A) and needing a driver (C) are correct.