Nokea
The nurse is caring for a client who is diagnosed with acute appendicitis. After several hours of pain, the client suddenly states a relief in his pain. What is the initial action of the nurse?
- A. Notify the physician
- B. Document the finding
- C. Insert an IV cannula
- D. Administer a laxative
Correct Answer: A
Rationale: Sudden pain relief in appendicitis (A) may indicate appendix rupture, a medical emergency requiring immediate physician notification.
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The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)?
- A. Muscle rigidity of the neck
- B. Hyperactive bowel sounds
- C. Frequent diarrhea
- D. Abdominal distention
Correct Answer: A
Rationale: Muscle rigidity of the neck (dystonia) is a serious extrapyramidal side effect of metoclopramide, requiring immediate PHCP notification. Hyperactive bowel sounds, diarrhea, and distention are less urgent or expected with gastroparesis.
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 nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply.
- A. Hyperglycemia
- B. Infection
- C. Air embolism
- D. Cardiac tamponade
- E. Dehydration
Correct Answer: A,B,C
Rationale: TPN risks include hyperglycemia (A) from high glucose content, infection (B) due to central line use, and air embolism (C) from improper line management. Cardiac tamponade (D) and dehydration (E) are less directly associated.
The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?
- A. Decreased abdominal cramping
- B. Absence of nausea and vomiting
- C. Decreased urinary retention
- D. Less burning with urination
Correct Answer: A
Rationale: Dicyclomine, an anticholinergic, reduces intestinal spasms, so decreased abdominal cramping indicates a therapeutic response. It is not primarily for nausea, urinary retention, or dysuria.
The following scenario applies to the next 1 items
The nurse is caring for a client immediately following an abdominal paracentesis
Item 1 of 1
Procedure Note
1845 - Emergency ultrasound-guided abdominal paracentesis was performed because the client presented with labored respirations, dyspnea, abdominal cramping, and overall discomfort. Informed consent was obtained, and the client agreed to the procedure. Prior to the procedure, the client emptied their bladder. The site was cleaned and numbed with 1% lidocaine, and using an aseptic technique and an ultrasound; a 14-gauge catheter was inserted to remove 10 mL of clear ascitic fluid. Subsequently, the fluid was drained via tubing. 6 liters of fluid were removed. The client tolerated the procedure well and reported immediate relief in the dyspnea and abdominal cramping following the procedure.
Immediately following this procedure, the nurse should monitor the client's ............. because the client has the risk of ........... If the client should experience this immediate post-procedure complication, the nurse should anticipate a prescription for ........
- A. Blood pressure
- B. Urinary output
- C. Hypotension
- D. Peritonitis
- E. Albumin
- F. Ceftriaxone
Correct Answer: A,C,E
Rationale: Monitor blood pressure (A) for hypotension (C) due to fluid shifts post-paracentesis. Albumin (E) is anticipated to restore intravascular volume if hypotension occurs.