Nokea
The nurse is assessing a client who may have a hiatal hernia. What symptom is the client most likely to report?
- A. Projectile vomiting
- B. Crampy lower abdominal pain
- C. Burning substernal pain
- D. Bloody diarrhea
Correct Answer: C
Rationale: Burning substernal pain, often mistaken for heartburn, is a hallmark symptom of hiatal hernia due to acid reflux.
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The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.
The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.
At a follow-up clinic visit, the client who had a sigmoid colectomy for colon cancer is instructed to take 325 mg of aspirin per day. The nurse explains to the client that the aspirin will have which effect?
- A. Help decrease the surgical pain
- B. Help heal the surgical incision
- C. Prevent the return of colon cancer
- D. Prevent metastasis of the cancer
Correct Answer: C
Rationale: Aspirin (Ecotrin) 325 mg taken daily has been shown to decrease the risk of recurrence of colon cancer.
The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.