Nokea
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
You may also like to solve these questions
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
Which disease is the client diagnosed with GERD at greater risk for developing?
- A. Hiatal hernia.
- B. Gastroenteritis.
- C. Esophageal cancer.
- D. Gastric cancer.
Correct Answer: C
Rationale: Chronic GERD increases the risk of esophageal cancer, particularly adenocarcinoma, due to prolonged acid exposure causing Barrett's esophagus, a precancerous condition. Hiatal hernia is a risk factor for GERD, not a consequence, and gastroenteritis and gastric cancer are less directly linked.
The client is diagnosed with peritonitis. Which assessment data indicate to the nurse the client's condition is improving?
- A. The client is using more pain medication on a daily basis.
- B. The client's nasogastric tube is draining coffee-ground material.
- C. The client has a decrease in temperature and a soft abdomen.
- D. The client has had two (2) soft-formed bowel movements.
Correct Answer: C
Rationale: A decrease in temperature and a soft abdomen indicate resolving infection and inflammation in peritonitis. Increased pain medication, coffee-ground drainage, and bowel movements are not improvement signs.
The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?
- A. The sodium level.
- B. The albumin level.
- C. The potassium level.
- D. The glucose level.
Correct Answer: C
Rationale: Potassium is critical to monitor in diarrhea due to risk of hypokalemia from losses, which can cause arrhythmias. Sodium is also relevant, but potassium is priority.