Nokea
The nurse is assigned to care for four clients. The nurse should plan to assess which client first?
- A. The client with ascites who is having mild dyspnea with activity
- B. The client with a peptic ulcer who now has severe vomiting
- C. The client who had a colonoscopy and is having diarrheal stools
- D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes
Correct Answer: D
Rationale: D. The client with Crohn’s disease who received an initial dose of certolizumab (Cimzia) and is having generalized rashes should be attended to first. Generalized rash indicates an allergic reaction. This could develop into an anaphylactic reaction. B. The client with a peptic ulcer who now has severe vomiting should be attended to second. Vomiting in PUD may indicate a complication such as mechanical obstruction from scarring. C. The client who had a colonoscopy and is having diarrheal stools should be attended to third. Diarrhea may have been the indication for the client’s colonoscopy or a side effect of the bowel prep. A. The client with ascites who is having mild dyspnea with activity can be attended to last. The dyspnea is usually due to the enlarged abdomen.
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The nurse is caring for an adult client diagnosed with GERD. Which condition is the most common comorbid disease associated with GERD?
- A. Adult-onset asthma.
- B. Pancreatitis.
- C. Peptic ulcer disease.
- D. Increased gastric emptying.
Correct Answer: A
Rationale: GERD is commonly associated with adult-onset asthma due to acid reflux irritating the airways, leading to bronchospasm. Pancreatitis and peptic ulcer disease are less directly linked, and increased gastric emptying is not a typical comorbidity.
The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask?
- A. When did you last eat?'
- B. Have you had surgery before?'
- C. Have you ever had this type of pain before?'
- D. What do you usually take to relieve your pain?'
Correct Answer: A
Rationale: Knowing when the client last ate is essential to minimize aspiration risk during anesthesia for anticipated appendicitis surgery.
The nurse is admitting the client for a colonoscopy. Which information, if found in the client’s medical record, should the nurse consider as the primary reason for this client’s colonoscopy?
- A. Chronic constipation
- B. Urostomy placed 3 years ago
- C. History of colon polyps
- D. Hemoglobin 10 g/dL
Correct Answer: C
Rationale: A. Although a colonoscopy may be performed to evaluate chronic constipation, this is less likely than evaluation of colon polyps. B. A urostomy is used for urinary diversion following bladder cancer; it does not affect the colon. C. Colonoscopy is used in screening and diagnosing colon cancer and for surveillance in persons with prior history of colon cancer or polyps. This is likely the primary reason for a colonoscopy with this client. D. An Hgb of 10 g/dL is slightly low. This could be a reason for a colonoscopy, especially if there is a pattern of low Hgb levels and the stool guaiac test is positive. However, this is less likely the primary reason than evaluation of colon polyps.
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 client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.