Nokea
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.
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The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.
A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis?
- A. I am a vegetarian.'
- B. My mother and grandmother have diabetes.'
- C. I take aspirin several times a day for tension headaches.'
- D. I take multivitamin and iron tablets every day.'
Correct Answer: C
Rationale: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Vegetarianism, family history of diabetes, and multivitamins with iron are not directly linked to duodenal ulcers.
The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?
- A. Teach the client to limit use of alcohol and drugs containing acetaminophen.
- B. Provide a high-protein, high-carbohydrate diet with three large meals per day.
- C. Wear gloves, mask, and gown when providing the client’s personal cares.
- D. Provide rest periods, alternating this with moderate activity during the day.
Correct Answer: D
Rationale: A. Clients with viral hepatitis should avoid all alcohol and all medications containing acetaminophen, not just limit their use. B. Clients should eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. C. It is not necessary to wear a mask when caring for an individual with hepatitis A. A gown and gloves should be worn when in contact with blood and body fluids. D. Rest is an essential intervention to decrease the liver’s metabolic demands and increase its blood supply. Rest should be alternated with periods of activity to prevent complications and to restore health.