Nokea
The nurse is assisting in positioning a client for a liver biopsy procedure. Which positioning is most appropriate for the client during the procedure?
- A. Prone position with the arms extended overhead.
- B. Supine position with the right arm abducted and the head turned to the left.
- C. Left lateral decubitus position with the right arm raised above the head.
- D. Trendelenburg position with the legs elevated and the head lowered.
Correct Answer: B
Rationale: Supine position with the right arm abducted and head turned to the left (B) provides optimal access to the liver and minimizes complications during a liver biopsy.
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While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention?
- A. The pain doesn't feel as bad now. I think it was just a stomach ache.
- B. Would you mind getting me an ice pack?
- C. I know I'm not supposed to eat anything right now, but I'm hungry.
- D. I wonder if I can play in the basketball game on Monday.
Correct Answer: A
Rationale: Sudden pain relief (A) in suspected appendicitis may indicate appendix rupture, requiring immediate intervention to prevent complications like peritonitis.
The following scenario applies to the next 6 items
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 1 of 6
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
The nurse is reviewing the client's admission information. Select the findings that require immediate follow-up.
- A. The client reports sudden severe epigastric pain radiating to the back.
- B. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension.
- C. His home medications include pantoprazole and lisinopril.
- D. Upon assessment, the client is noted to be alert and oriented x 4.
- E. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10.
- F. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea.
- G. Temperature is $101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
Correct Answer: A,E,G
Rationale: Severe epigastric pain radiating to the back (A), nausea and vomiting worsened by fatty foods (E), and vital sign abnormalities (G) such as fever, tachycardia, and hypotension suggest acute pancreatitis, requiring urgent follow-up.
The following scenario applies to the next 1 items
The nurse in the physician's office cares for a client looking to establish care
Item 1 of 1
Nurses' Notes
1709: 58-year-old African American male presents to the office looking to establish primary care. The client has not had a primary healthcare provider in over eleven years. The client requests a physical examination. The client reports that two months ago, he started noticing changes in his bowel habits, which alternate between diarrhea and constipation. The symptoms are accompanied by occasional dark, tarry stools. This past week, he has had constant abdominal pain that has ranged from a 5/10 to a 7/10 on the Numerical Rating Scale. He describes the pain as 'dull.' He reports that his diet has not changed, and he primarily eats red meat and sandwiches made with luncheon meats and occasionally vegetables. Currently, the client takes a daily aspirin and a multivitamin. He reports a medical history of oral herpes simplex and high blood pressure. He is overweight. He smokes cigarettes daily. On assessment, the client is alert and fully oriented, skin is warm and dry. Lung sounds are clear; the apical pulse is regular. Bowel sounds are active in all quadrants, with no abdominal distention. Capillary refill less than 3 seconds. Peripheral pulses palpable, 2+. Vital signs: T 97.5° F (36.4° C), P 97, RR 18, BP 161/92, pulse oximetry reading 96% on room air.
Orders
1719:
• Point of care (POC) hemoglobin and hematocrit
• Guaiac-based fecal occult blood test (gFOBT)
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Obtain an order for serum type and screen, obtain an order for a colonoscopy, educate the client on adopting a high fiber diet, request a prescription for an oral corticosteroid.
- B. Bowel obstruction, ulcerative colitis, colon cancer, peptic ulcer disease.
- C. Pain level, serum glucose level, bowel elimination pattern or habits, white blood cell (WBC) count.
Correct Answer: B: Colon cancer; A: Obtain an order for a colonoscopy, educate the client on adopting a high fiber diet; C: Pain level, bowel elimination pattern or habits
Rationale: Dark, tarry stools, changing bowel habits, and abdominal pain suggest colon cancer (B). Ordering a colonoscopy and promoting a high-fiber diet (A) aid diagnosis and management. Monitoring pain and bowel patterns (C) tracks progress.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 3 of 6
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
The client is at risk for developing........... and .......
- A. Cholelithiasis
- B. Pulmonary edema
- C. Gastrointestinal bleeding
- D. Intestinal obstruction
- E. Diabetic ketoacidosis (DKA)
- F. Hypovolemia
- G. Pulmonary embolism
Correct Answer: C,F
Rationale: Acute pancreatitis increases the risk of gastrointestinal bleeding (C) due to potential erosion of blood vessels and hypovolemia (F) from third-spacing and vomiting. Cholelithiasis (A) is less likely given normal gallbladder imaging.
The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. This action is appropriate and does not require follow-up. The nurse understands that the primary purpose of placing this tube is to
- A. Feed the client.
- B. Decompress the stomach.
- C. Irrigate the stomach.
- D. Administer medications.
Correct Answer: B
Rationale: A nasogastric tube in paralytic ileus (B) decompresses the stomach, relieving distention and preventing complications like aspiration.