Nokea
The nurse is admitting a patient to the emergency department who has had several episodes of bloody diarrhea. Which of the following actions should the nurse anticipate taking?
- A. Obtain a stool specimen for culture.
- B. Administer antidiarrheal medications.
- C. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs).
- D. Provide education about antibiotic therapy.
Correct Answer: A
Rationale: Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. NSAIDs may cause occult blood in the stools, but not diarrhea. Antidiarrheal medications usually are avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications.
You may also like to solve these questions
The nurse is caring for a patient with stomach cancer who had a recent 9.1 kg unintended weight loss. Which of the following nursing actions should be included in the plan of care?
- A. Refer the patient for hospice services.
- B. Infuse IV fluids through a central line.
- C. Teach the patient about antiemetic therapy
- D. Offer supplemental feedings between meals.
Correct Answer: D
Rationale: The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.
The nurse is admitting a patient with a stroke who is unconscious and unresponsive, learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). Which of the following assessment parameters should the nurse plan to assess frequently?
- A. Bowel sounds
- B. Pupillary response
- C. Grip strength
- D. Oral mucosa
Correct Answer: D
Rationale: Due to the patient's unconscious state and history of GERD, frequent assessment of the oral mucosa is crucial to monitor for complications such as aspiration or mucosal damage from reflux. Bowel sounds, pupillary response, and grip strength are important but less directly related to GERD complications in this context.
The nurse is counselling a patient with a family history of stomach cancer about risk factors. Which of the following is a risk factor for the development of stomach cancer?
- A. Type A blood
- B. Persistent abdominal distension
- C. Long-term use of H2 blocking medications
- D. Exposure to emotionally or physically stressful situations
Correct Answer: A
Rationale: Patients with Type A blood have an increased risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distension are not associated with an increased incidence of stomach cancer.
The nurse is assessing a patient who recently has been experiencing frequent 'heartburn' in the clinic. Which of the following information should the nurse include in the teaching plan?
- A. Barium swallow
- B. Radionuclide tests
- C. Endoscopy procedures
- D. Proton pump inhibitors
Correct Answer: D
Rationale: Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.
Which of the following presentations in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately?
- A. The patient is experiencing intermittent waves of nausea
- B. The patient has absent breath sounds throughout the left lung.
- C. The patient has decreased bowel sounds in all four quadrants.
- D. The patient complains of 6/10 (0-10 scale) abdominal pain.
Correct Answer: B
Rationale: Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.