Nokea
The nurse is caring for a client with diverticulosis who reports difficulty getting enough dietary fiber. The nurse should anticipate the primary healthcare provider (PHCP) will prescribe
- A. Psyllium
- B. Oil-retention enema
- C. Codeine
- D. Bisacodyl
Correct Answer: A
Rationale: Psyllium, a bulk-forming laxative, increases fiber intake, promoting regular bowel movements in diverticulosis. Enemas, codeine (which slows motility), and bisacodyl (a stimulant laxative) are not appropriate for increasing dietary fiber.
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The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 3 of 6
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
The client is at risk for developing........... and .......
- A. Cholelithiasis
- B. Pulmonary edema
- C. Gastrointestinal bleeding
- D. Intestinal obstruction
- E. Diabetic ketoacidosis (DKA)
- F. Hypovolemia
- G. Pulmonary embolism
Correct Answer: C,F
Rationale: Acute pancreatitis increases the risk of gastrointestinal bleeding (C) due to potential erosion of blood vessels and hypovolemia (F) from third-spacing and vomiting. Cholelithiasis (A) is less likely given normal gallbladder imaging.
A nurse is assigned to care for a client with liver dysfunction and ascites and is ordered to measure the client's abdominal girth daily. To ensure accuracy, the nurse should utilize which landmark?
- A. Xiphoid process
- B. Umbilicus
- C. Iliac crest
- D. Symphysis pubis
Correct Answer: B
Rationale: The umbilicus (B) is a consistent anatomical landmark for measuring abdominal girth in ascites, ensuring accurate and reproducible measurements.
While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention?
- A. The pain doesn't feel as bad now. I think it was just a stomach ache.
- B. Would you mind getting me an ice pack?
- C. I know I'm not supposed to eat anything right now, but I'm hungry.
- D. I wonder if I can play in the basketball game on Monday.
Correct Answer: A
Rationale: Sudden pain relief (A) in suspected appendicitis may indicate appendix rupture, requiring immediate intervention to prevent complications like peritonitis.
The nurse has provided medication instruction to a client prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication one hour after meals.
- B. I will remain upright for 30 minutes after taking this medicine.
- C. This medication will help with my peptic ulcer disease.
- D. I know this medication works when my nausea and vomiting are gone.
- E. I may dissolve this medication in warm water.
Correct Answer: A,D,E
Rationale: Sucralfate is taken 1 hour before meals, not after; it treats ulcers but does not primarily relieve nausea/vomiting; and it should not be dissolved in water. Remaining upright and ulcer treatment are correct.