Nokea
The nurse is caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement?
- A. Perform a complete pain assessment.
- B. Assess the client's vital signs frequently.
- C. Administer a proton pump inhibitor intravenously.
- D. Obtain permission and administer blood products.
- E. Monitor the intake of a soft, bland diet.
Correct Answer: B,C,D
Rationale: Frequent vital sign assessment monitors for hypovolemia, IV proton pump inhibitors reduce acid and bleeding, and blood products treat anemia from hemorrhage. Pain assessment is important but less urgent, and a bland diet is inappropriate during active bleeding.
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The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse?
- A. The client has 20 bloody stools a day.
- B. The client's oral temperature is 99.8°F.
- C. The client's abdomen is hard and rigid.
- D. The client complains of urinating when coughing.
Correct Answer: C
Rationale: A hard, rigid abdomen suggests peritonitis or perforation, a life-threatening complication of ulcerative colitis requiring immediate intervention. Frequent bloody stools are expected, low-grade fever is less urgent, and urinary incontinence is unrelated.
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
During a health promotion seminar for senior citizens, a participant asks the nurse to discuss symptoms of gastric cancer. Which statement should be the basis for the nurse’s response?
- A. Cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients.
- B. Pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists.
- C. Unexplained weight gain and increased body mass index (BMI) are early symptoms of gastric cancer.
- D. Anemia is uncommon in gastric cancer, but if it occurs, it is likely due to the effects of aging.
Correct Answer: A
Rationale: A. Eighty percent of clients with early gastric cancer do not have symptoms. B. Pain caused by gastric cancer can be alleviated by OTC histamine receptor antagonists. C. Weight loss and anemia are common symptoms, not weight gain and increased BMI. D. Anemia occurs from malabsorption and nutritional deficiencies, not the effects of aging.
The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.