Nokea
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
- A. Hyperactive bowel sounds.
- B. Rigid abdominal wall.
- C. Explosive diarrhea.
- D. Excessive flatulence.
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.
You may also like to solve these questions
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
- A. Administer surfactant
- B. Provide high-flow oxygen
- C. Initiate antibiotic therapy
- D. Perform chest physiotherapy
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.
The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain a 3-mL syringe with a 1/2-inch needle for the injection.
- C. Mark the test area to locate it for reading 48 to 72 hours after injection.
- D. Bunch up the skin and insert the needle with the needle bevel facing downward.
- E. Cleanse the injection site on the lower dorsal surface of the forearm with alcohol and allow it to dry.
- F. Ask the client about a history of receiving a positive purified protein derivative (PPD) reaction.
Correct Answer: A,C,E,F
Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.
A new mother was administered methylergonovine maleate intramuscularly after delivery. The nurse understands that this medication was administered for which action?
- A. Decrease uterine contractions.
- B. Prevent postpartum hemorrhage.
- C. Maintain a normal blood pressure.
- D. Reduce the amount of lochia drainage.
Correct Answer: B
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The first dose is usually administered intramuscularly, and then if it needs to be continued, it is given by mouth. It increases the strength and frequency of contractions and may elevate blood pressure. There is no relationship between the action of this medication and lochia drainage.
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
- A. Vertigo.
- B. Tinnitus.
- C. Nausea.
- D. Ataxia.
- E. Hearing loss.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.
A client with a history of heart failure is admitted with worsening symptoms. The nurse should monitor the client for which of the following laboratory abnormalities? Select all that apply.
- A. Hyponatremia.
- B. Hyperkalemia.
- C. Elevated B-type natriuretic peptide (BNP).
- D. Hypomagnesemia.
- E. Elevated creatinine.
Correct Answer: A, C, E
Rationale: Heart failure can cause hyponatremia (fluid overload), elevated BNP (cardiac stress), and elevated creatinine (renal impairment).