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The nurse is caring for a patient who has an obstruction of the common bile duct. Which of the following findings should the nurse monitor in this patient?
- A. Melena
- B. Steatorrhea
- C. Decreased serum cholesterol levels
- D. Increased serum indirect bilirubin levels
Correct Answer: B
Rationale: A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction.
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The health care provider sees a patient at 10 A.M. and writes a prescription for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which of the following actions that are included in the agency protocol for ERCP should the nurse take first?
- A. Place the patient on NPO status.
- B. Administer sedative medications.
- C. Ensure the consent form is signed.
- D. Explain the procedure to the patient.
Correct Answer: A
Rationale: The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse's initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO.
The nurse is listening to a patient's abdomen. Which of the following findings indicate a need for a focused abdominal assessment?
- A. Loud gurgles
- B. High-pitched gurgles
- C. Absent bowel sounds
- D. Frequent clicking sounds
Correct Answer: C
Rationale: Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.
The nurse is preparing to assess a patient's liver. When palpating the liver, which of the following techniques should the nurse implement?
- A. Place one hand on the patient's back and press upward and inward with the other hand below the patient's right costal margin.
- B. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge.
- C. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt.
- D. Place one hand under the patient's lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand.
Correct Answer: A
Rationale: The liver is normally not palpable below the costal margin, the nurse needs to push inward below the right costal margin while lifting the patient's back slightly with the left hand. The other methods will not allow palpation of the liver.
Which of the following actions by a nursing student when caring for a patient who has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the RN intervene?
- A. Offering the patient a glass of water
- B. Positioning the patient on the right side
- C. Checking the vital signs every 30 minutes
- D. Swabbing the patient's mouth with cold water
Correct Answer: A
Rationale: Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. The patient should be NPO for 2-4 hours. Assessment for return of the gag reflex should be done prior to administering any fluids by mouth. The other actions by the student are appropriate.
The nurse is assessing an alert and independent older-adult patient in the clinic for malnutrition risk. Which of the following questions is best as the initial assessment question?
- A. How do you get to the grocery store to buy your food?
- B. Do you have any difficulty in preparing or eating food?
- C. Can you tell me the foods that you have eaten over the past 24 hours?
- D. Are you taking any medications that alter your taste or tolerance of foods?
Correct Answer: C
Rationale: This question is the most open-ended and will provide the best overall information about the patient's daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient's response to the first question.