Nokea
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns of dietary intake.
- B. Activity level of bowel sounds.
- C. Level and amount of physical activity.
- D. Color and consistency of feces.
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.
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The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care?
- A. Ensure oral suction is available.
- B. Provide frequent mouth care.
- C. Keep the room at a comfortable temperature.
- D. Maintain the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring oral suction is available is the most essential intervention to maintain a clear airway and prevent aspiration during and after seizures, particularly in an unconscious client.
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
- A. Topical antifungal.
- B. Topical corticosteroids.
- C. Topical analgesics.
- D. Colloidal oatmeal based lotion.
Correct Answer: B
Rationale: Topical corticosteroids are commonly used to reduce inflammation and itching associated with psoriasis, controlling symptoms and promoting healing.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Alternate IV and IM analgesic medications.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Educate client on signs and symptoms of narcotic dependency.
Correct Answer: B
Rationale: Administering opioid and non-opioid medication simultaneously addresses severe pain from multiple pathways, providing effective relief for stage IV bone cancer.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Crohn's disease with colectomy.
- B. Latent hepatitis C.
- C. Type 2 diabetes mellitus.
- D. Nephrotic syndrome history.
Correct Answer: A
Rationale: Crohn's disease with colectomy is a contraindication for peritoneal dialysis due to the risk of infection or inadequate dialysis from compromised peritoneal integrity.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
The nurse is caring for a client who was admitted to the hospital with reports of shortness of breath, fever, fatigue, and oral thrush three days ago. The health care provider reviews the laboratory and diagnostic tests with the client and informs of the diagnosis of Pneumocystis pneumonia. The client reports that they recently tested HIV positive. The nurse reviews the client's medical record.
HIV diagnosed 4 months ago with no medications prescribed.
Note added to H&P reporting client wishes to be confidential since family and friends are unaware of the HIV diagnosis.
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
- A. Increase IV fluids to 150 mL/hr
- B. Monitor for adverse reaction to antibiotics
- C. Repeat CD4+ T-cell count STAT
- D. Initiate airborne isolation
- E. Administer antiemetic
Correct Answer: A,B,E
Rationale: Increasing IV fluids, monitoring for antibiotic reactions, and administering an antiemetic address the client's fever, potential infection, and nausea associated with Pneumocystis pneumonia.