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The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-Whipple complication. Options A, C, and D are normal.
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The client taking allopurinol (Zyloprim) should be taught to:
- A. Drink approximately eight glasses of water per day.
- B. Avoid the intake of fruits.
- C. Allow 6 weeks for the drug to work.
- D. Eat foods containing purine.
Correct Answer: A
Rationale: Allopurinol prevents uric acid buildup, and adequate hydration (eight glasses of water) reduces kidney stone risk. Fruits are not restricted, the drug works sooner, and purine foods should be limited.
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. His abdomen is distended, and there are no bowel sounds.
The FIRST nursing action should be to
- A. administer the PRN pain medication and an antiemetic.
- B. irrigate the nasogastric tube with normal saline.
- C. determine if the nasogastric tube is patent and draining.
- D. check the placement of the nasogastric tube by auscultation.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. (1) implementation, may be carried out after the patency of the tube is determined (2) implementation, patency should be checked first (3) correct-should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining it does not need to be irrigated (4) assessment, patency should be checked first by aspirating stomach contents, not by auscultation
The nurse is assisting the physician with the insertion of a central venous catheter. Which statement best explains the rationale for placing the client in Trendelenburg position?
- A. It will make catheter insertion easier.
- B. It will make the client more comfortable.
- C. It will prevent ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: Trendelenburg position elevates the veins, making central venous catheter insertion easier. Comfort , tachycardia , and emboli are not primary concerns.
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
- A. It is common in children who take barbiturates.
- B. It usually occurs after seizures; let him sleep.
- C. It is probably not related to his seizure disorder or treatment.
- D. It is probably a warning sign that he is about to have a seizure.
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.
A client is seen in the emergency room with complaints of chest pain.
- A. Which assessment finding suggests to the nurse that the client’s chest pain is cardiac in origin?
- B. The client states that the pain is sharp and increased by deep breathing.
- C. The client reports a history of a fatty meal before the pain began.
- D. The client states that the pain is substernal and radiates to the left arm.
- E. The client reports that the pain began when he was lifting a heavy object.
Correct Answer: C
Rationale: Substernal chest pain radiating to the left arm is a classic symptom of cardiac ischemia, such as angina or myocardial infarction. Sharp pain with breathing suggests pleuritic causes, fatty meals indicate gastroinTest inal issues, and pain with lifting suggests musculoskeletal strain.