Nokea
The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurse’s priority when monitoring for GI bleeding?
- A. The 40-year-old client who is positive for Helicobacter pylori (H. pylori)
- B. The 45-year-old client who drinks 4 ounces of alcohol a day
- C. The 70-year-old client who takes daily baby aspirin of 81 mg
- D. The 30-year-old pregnant client taking acetaminophen prn
Correct Answer: C
Rationale: A. The presence of H. pylori has not been proven to predispose to GI bleeding. B. Although alcohol is associated with gastric mucosal injury, its causative role in bleeding is unclear. C. It is most important for the nurse to monitor the 70-year-old client who is taking aspirin. The client has two risk factors for GI bleeding: age and taking aspirin. D. Pregnancy and acetaminophen usage do not predispose to GI bleeding.
You may also like to solve these questions
Which instruction should be discussed with the client diagnosed with gastroesophageal reflux disease (GERD)?
- A. Eat a low-carbohydrate, low-sodium diet.
- B. Lie down for 30 minutes after eating.
- C. Do not eat spicy foods or acidic foods.
- D. Drink two (2) glasses of water before bedtime.
Correct Answer: C
Rationale: Avoiding spicy and acidic foods reduces esophageal irritation, a key instruction for managing GERD. Low-carb/sodium diets are not specific, lying down after eating worsens reflux, and water before bedtime is irrelevant.
The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.
The client is being admitted to the outpatient psychiatric clinic diagnosed with bulimia. Which question should the nurse ask to identify behaviors suggesting bulimia?
- A. When was the last time you exercised?
- B. What over-the-counter medications do you take?
- C. How long have you had a positive self-image?
- D. Do you eat a lot of high-fiber foods for bowel movements?
Correct Answer: B
Rationale: Asking about OTC medications identifies purging behaviors (e.g., laxatives, diuretics) common in bulimia. Exercise, self-image, and fiber intake are less specific.
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.
The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first?
- A. Ask the client why she is eating too much.
- B. Refer the client to a gymnasium for exercise.
- C. Have the client set a realistic weight loss goal.
- D. Determine the client's eating patterns.
Correct Answer: D
Rationale: Determining eating patterns identifies triggers and habits, guiding weight loss interventions. Asking why is confrontational, gym referral is premature, and goal-setting follows assessment.