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 client who has had a hemorrhoidectomy wants to know why she cannot take a sitz bath immediately upon return from the operating room. The nurse's response is based on which of the following concepts?
- A. Heat can stimulate bowel movement too quickly after surgery.
- B. Clients are generally not awake enough for several hours to safely take sitz baths.
- C. Heat applied immediately postoperatively increases the possibility of hemorrhage.
- D. Sitting in water before the sutures are removed may cause infection.
Correct Answer: C
Rationale: Heat increases blood flow, raising the risk of hemorrhage immediately post-hemorrhoidectomy.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.
The client diagnosed with liver failure is experiencing pruritus secondary to severe jaundice. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?
- A. The UAP is assisting the client to take a hot, soapy shower.
- B. The UAP applies an emollient to the client's legs and back.
- C. The UAP puts mittens on both hands of the client.
- D. The UAP pats the client's skin dry with a clean towel.
Correct Answer: A
Rationale: Hot, soapy showers can worsen pruritus by drying the skin, requiring intervention. Emollients, mittens (to prevent scratching), and patting dry are appropriate.
The client is admitted to a hospital for medical management of acute diverticulitis. The nurse should anticipate that this client’s treatment plan will include which component?
- A. NPO (nothing per mouth) status
- B. Frequent ambulation
- C. Prescribed antibiotics
- D. Antiemetic medication
- E. Deep breathing every 2 hours
Correct Answer: A, C
Rationale: The nurse should plan for the client to be NPO. Medical management for diverticulitis includes resting the bowel. NPO status will help to achieve this. B. Ambulation is not encouraged; resting the body promotes bowel rest. C. Broad-spectrum antibiotics effective against known enteric pathogens are used in treating every stage of diverticulitis. D. Nausea is not a concern with diverticulitis. E. The client did not have surgery; there is no need for deep breathing every 2 hours.
A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis?
- A. I am a vegetarian.'
- B. My mother and grandmother have diabetes.'
- C. I take aspirin several times a day for tension headaches.'
- D. I take multivitamin and iron tablets every day.'
Correct Answer: C
Rationale: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Vegetarianism, family history of diabetes, and multivitamins with iron are not directly linked to duodenal ulcers.