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The nurse is caring for a client in the intensive care unit (ICU) being mechanically ventilated via an endotracheal tube (ETT) for head trauma following a motor vehicle crash (MVC). The primary healthcare provider (PHCP) prescribes famotidine 20 mg intravenous (IV) push. The nurse understands that this medication is intended to
- A. Decrease any gagging by the ETT
- B. Prevent the formation of stress ulcers
- C. Provide sedation
- D. Increase gastric motility
Correct Answer: B
Rationale: Famotidine, an H2 blocker, is used in ICU settings to prevent stress ulcers by reducing gastric acid. It does not affect gagging, provide sedation, or increase motility.
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The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated?
- A. Administering gastrografin for an upper GI x-ray.
- B. An exploratory laparotomy procedure.
- C. Administering milk of magnesia following an upper GI study.
- D. An abdominal CT scan.
Correct Answer: C
Rationale: Milk of magnesia (C) is contraindicated in suspected bowel perforation as it may worsen the condition by increasing intestinal motility or causing further leakage. Gastrografin (A), laparotomy (B), and CT scans (D) are appropriate diagnostic or therapeutic measures.
The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply.
- A. I will not be able to eat or drink anything for six to eight hours before this procedure.
- B. I will have to do a bowel prep before this procedure.
- C. Someone will have to drive me home after this procedure.
- D. I should notify my physician if I have abdominal pain and distention for one or two days following this procedure.
- E. I can expect to have white stools one to two days following this procedure.
Correct Answer: B,D,E
Rationale: Bowel prep (B) is not typically required for ERCP. Persistent pain and distention (D) post-ERCP require immediate notification, not delayed. White stools (E) are not expected post-ERCP. Fasting (A) and needing a driver (C) are correct.
The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.
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 nurse has taught a client scheduled for a liver biopsy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will not be conscious during this procedure.
- B. I should not take any acetaminophen one week before this procedure.
- C. I will need to cough and deep breathe every two hours after this procedure.
- D. I may be asked to hold my breath during the insertion of the biopsy needle.
Correct Answer: D
Rationale: Holding the breath (D) during needle insertion stabilizes the liver, reducing complications. The procedure is typically done under local anesthesia (A is incorrect), acetaminophen restriction (B) is not standard, and coughing (C) is not required post-procedure.