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The nurse is caring for a client with a hiatal hernia who is being discharged today. The nurse talks to them regarding methods to manage symptoms and promote overall well-being associated with their condition. Which of the following statements from the client indicate that teaching is successful?
- A. I need to wear loose-fitting clothes.
- B. After a meal, I must lie down to avoid dumping syndrome.
- C. I need to eat three large meals a day.
- D. I can go to my favorite Indian restaurant anytime of the week.
Correct Answer: A
Rationale: Wearing loose-fitting clothes (A) reduces pressure on the stomach, helping manage hiatal hernia symptoms. Lying down after meals (B) can worsen reflux, large meals (C) increase symptoms, and spicy foods (D) may exacerbate reflux.
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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 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.
The following scenario applies to the next 1 items
The nurse is caring for a client who presents with acute appendicitis
Item 1 of 1
History of Present Illness
19-year-old female admitted with abdominal pain localized to the right lower quadrant. The onset of pain was twelve hours ago, and the client now reports pain is worsening when the client coughs. Endorses nausea and has persistent vomiting.
Vital Signs
• Oral temperature 101° F (38.3°C)
• Pulse 90/minute
• Respirations 18/minute
• Blood Pressure 110/66 mm Hg
• Oxygen saturation 96% on room air
Laboratory Results
• White blood cell count, 11,500 mm3 (5,000-10,000 mm3)
• Creatinine, 0.9 mg/dL (0.6-1.2 mg/dL)
• BUN 26 mg/dL (10-20 mg/dL)
• Potassium 3.3 mEq/L (3.5-5 mEq/L)
Select two (2) findings from the clinical data that require immediate follow-up
- A. Oral temperature 101°F (38.3°C)
- B. White blood cell count, 11,500 mm³
- C. Creatinine, 0.9 mg/dL
- D. Nausea and vomiting
- E. Potassium 3.3 mEq/L
- F. BUN 26 mg/dL
- G. Reports of pain increasing while coughing
Correct Answer: A,D
Rationale: Fever (A) and nausea/vomiting (D) in appendicitis suggest ongoing inflammation or complications, requiring immediate follow-up to prevent rupture or peritonitis.
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 nurse is caring for a client with a paralytic ileus following an appendectomy. Which intervention would be appropriate for the nurse to take?
- A. Assess the client for hyperkalemia
- B. Prepare for the insertion of a nasogastric tube
- C. Assess the surgical wound for approximation
- D. Instruct the client to chew their food more slowly
Correct Answer: B
Rationale: A nasogastric tube (B) is appropriate for gastric decompression in paralytic ileus to relieve distention and prevent complications. Hyperkalemia (A), wound assessment (C), and chewing instructions (D) are not directly relevant.