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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.
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The nurse is caring for a patient with peptic ulcer disease associated with the presence of Helicobacter pylori and is being treated with triple drug therapy. Which of the following medications should the nurse include in the patient teaching?
- A. Sucralfate, nystatin, and bismuth
- B. Amoxicillin, clarithromycin, and omeprazole
- C. Famotidine, magnesium hydroxide, and pantoprazole
- D. Metoclopramide, bethanechol, and promethazine
Correct Answer: B
Rationale: The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection.
The nurse is caring for a patient with vomiting of 'coffee-ground' emesis. Which of the following procedures should the nurse anticipate for the patient?
- A. Endoscopy
- B. Angiography
- C. Gastric analysis testing
- D. Barium contrast studies
Correct Answer: A
Rationale: Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding.
Which of the following assessment findings in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider?
- A. Absent bowel sounds
- B. Scant nasogastric (NG) tube drainage
- C. Complaints of incisional pain
- D. Temperature 38.9°C (102°F)
Correct Answer: D
Rationale: An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.
The health care provider prescribes the following therapies for a patient who has been admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which order should the nurse implement first?
- A. Infuse normal saline at 250 ml/hour.
- B. Administer IV ondansetron.
- C. Provide oral care with moistened swabs.
- D. Insert a nasogastric (NG) tube.
Correct Answer: A
Rationale: Because the patient has severe dehydration, rehydration with IV fluids is the priority. The other orders should be accomplished as quickly as possible after the IV fluids are initiated.
The nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer. Which of the following findings is of most concern?
- A. Bleeding during tooth brushing
- B. Painful blisters at the border of the lips
- C. Red, velvety patches on the buccal mucosa
- D. White, curdlike plaques on the posterior tongue
Correct Answer: C
Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (90%) of progression to malignant cancer. The other lesions are suggestive of acute processes (gingivitis, oral candidiasis, and herpes simplex).