Nokea
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.
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The nurse is caring for a 9-year-old client with cystic fibrosis who is scheduled to receive pancrelipase at 1200. The client states, 'I am not hungry now. I want to eat lunch in a few hours.' Which of the following actions should the nurse take?
- A. Omit the dose of medication.
- B. Administer half the dose of medication.
- C. Administer the dose of medication with a small snack
- D. Hold the dose of medication until the client is ready to eat.
Correct Answer: C
Rationale: Pancrelipase aids digestion in cystic fibrosis and should be taken with food. A small snack (C) ensures enzyme effectiveness while respecting the child’s appetite. Omitting (A) or halving (B) the dose risks malabsorption, and holding (D) delays nutrition.
A client is diagnosed as having secondary Cushing's syndrome. The nurse knows that the client has most likely been taking which medication?
- A. Estrogen
- B. Penicillin
- C. Lovastatin
- D. Prednisone
Correct Answer: D
Rationale: Secondary Cushing's syndrome is often caused by long-term prednisone use, a corticosteroid mimicking cortisol excess. Estrogen, penicillin, or lovastatin do not cause this condition.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?
- A. Lochia that soaks a perineal pad every 2 hours
- B. Persistent headache with blurred vision
- C. Red, painful nipple on one breast
- D. Strong-smelling vaginal discharge
Correct Answer: B
Rationale: Headache with blurred vision (B) suggests preeclampsia, a life-threatening condition requiring immediate intervention. Lochia (A), nipple pain (C), and discharge (D) are normal or less urgent postpartum findings.
Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)
A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?
- A. Check for hematuria
- B. Check for peaked T waves
- C. Obtain prescription for epoetin alfa
- D. Place a face mask on the client
Correct Answer: D
Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (D) protects the client. Hematuria (A), peaked T waves (B), and epoetin (C) address other issues not directly indicated.