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The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.
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The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
The client is admitted to the hospital complaining of malaise, abdominal discomfort, and severe diarrhea. The diagnosis is possible Crohn's disease. The client says that he has lost 27 pounds in the last four months even though he has not been dieting. To plan nursing care, which assessment data are most essential for the nurse to obtain?
- A. Approximate number and characteristics of stools each day
- B. Amount of liquid consumed daily
- C. History of previous gastric surgery
- D. Bowel sounds in the right lower quadrant
Correct Answer: A
Rationale: Frequent stools are characteristic of Crohn’s disease, and their number and characteristics are critical for assessing dehydration and skin breakdown risks.
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
The nurse is assessing the client recovering from abdominal surgery who has a patient-controlled analgesia (PCA) pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement?
- A. Insist the client take deep breaths.
- B. Notify the surgeon to request a chest x-ray.
- C. Determine the last time the client used the PCA pump.
- D. Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: C
Rationale: Determining PCA use assesses if overmedication is causing shallow respirations, guiding further action. Insisting on breathing, x-rays, or oxygen are secondary without cause.
Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.