Nokea
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.
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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.
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 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 in the emergency department (ED) cares for a 21-year-old male client
Item 1 of 1
Nurses' Notes
1650: Client reports severe abdominal pain that radiates to his left shoulder. The client was tossing around the football with friends, and after being tackled, he began experiencing intense pain that worsened. He denies any medical history but is currently being treated for infectious mononucleosis and 'needed to get some fresh air,' so he started playing football with friends. During the assessment, the client was alert and fully oriented. He reports his abdominal pain is in the left upper quadrant, which radiates to his shoulder, as an 8/10 on the Numerical Rating Scale. Slight bruising was noted on the client's abdomen. A blotchy rash was observed on his back. His abdomen was slightly distended, taut, and tender to touch. Lung sounds are clear bilaterally. Peripheral pulses 2+. Skin is hot to the touch. Cervical lymphadenopathy is present. Vital signs: T 100.4°F (38°C), P 110, RR 21, BP 115/76.
Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. Reports of abdominal pain
- B. Temperature
- C. Pulse
- D. Rash
- E. Cervical lymphadenopathy
- F. Abdominal assessment findings
Correct Answer: A,C,F
Rationale: Severe abdominal pain (A), elevated pulse (C), and abnormal abdominal findings (F) such as distention and tenderness suggest a serious condition like a ruptured spleen, especially given the history of trauma and infectious mononucleosis. These require urgent evaluation.
You are caring for a client who is in the burn unit with severe burns. Since this is your first client contact with this person, you introduce yourself and tell the client that they will be taken care of by you for this shift. The client greets you and states, 'Why am I getting this stuff that is hanging up here?' as they are pointing to the ordered total parenteral infusion. You should:
- A. Respond to the client stating, 'I don't think you should be getting this. I am going to call your doctor.'
- B. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired as the result of your burns'.
- C. Respond to the client stating, 'This is total parenteral nutrition and you are getting it because your nutritional status is impaired because you aren't eating enough.'
- D. Respond to the client stating, 'I don't think you should be getting this. I am going to turn it off now.'
Correct Answer: B
Rationale: TPN (B) is used in burn patients to meet high nutritional demands when oral intake is insufficient due to metabolic stress from burns, not just lack of eating (C). Options A and D are inappropriate as they suggest stopping or questioning a valid treatment.