Nokea
The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication?
- A. It prevents the final transport of hydrogen ions into the gastric lumen.
- B. It blocks receptors controlling hydrochloric acid secretion by the parietal cells.
- C. It protects the ulcer from the destructive action of the digestive enzyme pepsin.
- D. It neutralizes the hydrochloric acid secreted by the stomach.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) inhibit the H+/K+ ATPase pump, preventing hydrogen ion transport into the gastric lumen, thus reducing acid production to promote ulcer healing. Blocking receptors is for H2 antagonists, pepsin protection is for mucosal agents, and neutralization is for antacids.
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The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.
The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first?
- A. Ask the client why she is eating too much.
- B. Refer the client to a gymnasium for exercise.
- C. Have the client set a realistic weight loss goal.
- D. Determine the client's eating patterns.
Correct Answer: D
Rationale: Determining eating patterns identifies triggers and habits, guiding weight loss interventions. Asking why is confrontational, gym referral is premature, and goal-setting follows assessment.
The client is admitted to a hospital for medical management of acute diverticulitis. The nurse should anticipate that this client’s treatment plan will include which component?
- A. NPO (nothing per mouth) status
- B. Frequent ambulation
- C. Prescribed antibiotics
- D. Antiemetic medication
- E. Deep breathing every 2 hours
Correct Answer: A, C
Rationale: The nurse should plan for the client to be NPO. Medical management for diverticulitis includes resting the bowel. NPO status will help to achieve this. B. Ambulation is not encouraged; resting the body promotes bowel rest. C. Broad-spectrum antibiotics effective against known enteric pathogens are used in treating every stage of diverticulitis. D. Nausea is not a concern with diverticulitis. E. The client did not have surgery; there is no need for deep breathing every 2 hours.
The client has severe liver disease. Which of the following observations is most indicative of serious problems?
- A. The client has generalized urticaria.
- B. The client is 'confused' and can no longer write his name legibly.
- C. The client is jaundiced.
- D. The client has ecchymotic areas on his arms.
Correct Answer: B
Rationale: Confusion and impaired handwriting suggest hepatic encephalopathy, a serious complication of liver disease due to ammonia buildup.
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
- A. Pain related to heartburn from gastric reflux.
- B. Aspiration related to regurgitation of food accumulated in the diverticula.
- C. Constipation related to anatomical changes of the sigmoid colon.
- D. Altered nutrition, less than body requirements related to dysphagia.
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.