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The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
- A. Right upper quadrant, radiating to the right shoulder.
- B. Right upper quadrant, radiating to the left shoulder.
- C. Right lower quadrant, radiating to the pelvic bones.
- D. Right lower quadrant, radiating to the umbilicus.
Correct Answer: A
Rationale: Cholecystitis typically causes pain in the right upper quadrant radiating to the right shoulder (A) due to gallbladder inflammation and referred pain via the phrenic nerve.
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The nurse is developing a teaching plan for a client with post-gastrectomy dumping syndrome. Which of the following statements should the nurse make to the client?
- A. Take small sips of water during meals to soften the food for easier digestion.
- B. Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery.
- C. Plan rest periods of 10 minutes after every meal.
- D. Meals should consist of dry foods with low carbohydrates, moderate fat, and high protein content.
Correct Answer: D
Rationale: Dry, low-carbohydrate, moderate-fat, high-protein meals (D) slow gastric emptying, reducing dumping syndrome symptoms. Sips during meals (A), expecting resolution in 4-6 weeks (B), or short rest periods (C) are incorrect.
The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
The nurse is caring for a client diagnosed with peptic ulcer disease. The nurse anticipates a prescription for which medication?
- A. Ondansetron
- B. Diphenoxylate with atropine
- C. Famotidine
- D. Psyllium
Correct Answer: C
Rationale: Famotidine, an H2 receptor blocker, reduces gastric acid production, aiding in peptic ulcer healing. Ondansetron is for nausea, diphenoxylate-atropine for diarrhea, and psyllium for constipation, none of which treat ulcers directly.
The nurse is assessing a client diagnosed with necrotizing pancreatitis. Which of the following assessment findings would be expected?
- A. Ecchymotic discoloration in the periumbilical region
- B. Dysuria
- C. Hyperactive bowel sounds
- D. Hematuria
Correct Answer: A
Rationale: Ecchymotic discoloration in the periumbilical region (A), known as Cullen's sign, is expected in necrotizing pancreatitis due to retroperitoneal hemorrhage.
The following scenario applies to the next 1 items
The nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
• Oral temperature 101° F (38.3°C)
• Pulse 90/minute
• Respirations 18/minute
• Blood Pressure 110/66 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
• White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
• Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
• BUN 26 mg/dL (10-20 mg/dL)
• Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
- A. Oral temperature 101°F (38.3°C)
- B. White blood cell count, 11,500 mm³
- C. Creatinine, 0.9 mg/dL
- D. Nausea and vomiting
- E. Potassium 3.3 mEq/L
- F. BUN 26 mg/dL
- G. Reports of pain increasing while coughing
Correct Answer: A,D
Rationale: Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.