Nokea
The nurse is caring for a patient with acute gastrointestinal (GI) bleeding who is receiving normal saline IV at a rate of 500 ml/hour. Which of the following findings obtained by the nurse is most important to communicate immediately to the health care provider?
- A. The patient's blood pressure (BP) has increased to 142/94 mm Hg.
- B. The nasogastric (NG) suction is returning coffee-ground material.
- C. The patient's lungs have crackles audible to the midline.
- D. The bowel sounds are very hyperactive in all four quadrants.
Correct Answer: C
Rationale: The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return of the coffee-ground material in an NG tube is expected for a patient with upper GI bleeding. The BP is slightly elevated but would not be an indication to contact the health care provider immediately. Hyperactive bowel sounds are common when the patient has GI bleeding.
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The nurse is counselling a patient with a family history of stomach cancer about risk factors. Which of the following is a risk factor for the development of stomach cancer?
- A. Type A blood
- B. Persistent abdominal distension
- C. Long-term use of H2 blocking medications
- D. Exposure to emotionally or physically stressful situations
Correct Answer: A
Rationale: Patients with Type A blood have an increased risk for stomach cancer. Use of H2 blockers, stressful situations, and abdominal distension are not associated with an increased incidence of stomach cancer.
Twelve hours after undergoing a gastroduodenostomy (Billroth II), a patient has symptoms of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. Which of the following actions should the nurse take next?
- A. Notify the surgeon.
- B. Irrigate the NG tube.
- C. Administer the prescribed morphine.
- D. Continue to monitor the NG drainage.
Correct Answer: A
Rationale: Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. The patient may need morphine, but this is not the highest priority action. Continuing to monitor the NG drainage is not an adequate response.
The nurse is admitting a patient with a stroke who is unconscious and unresponsive, learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). Which of the following assessment parameters should the nurse plan to assess frequently?
- A. Bowel sounds
- B. Pupillary response
- C. Grip strength
- D. Oral mucosa
Correct Answer: D
Rationale: Due to the patient's unconscious state and history of GERD, frequent assessment of the oral mucosa is crucial to monitor for complications such as aspiration or mucosal damage from reflux. Bowel sounds, pupillary response, and grip strength are important but less directly related to GERD complications in this context.
A patient recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. Which of the following information should the nurse teach to the patient to avoid recurrence of these symptoms?
- A. Lie down for about 30 minutes after eating.
- B. Choose foods that are high in carbohydrates.
- C. Increase the amount of fluid intake with meals.
- D. Drink sugared fluids or eat candy after each meal.
Correct Answer: A
Rationale: The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.
Which of the following presentations in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately?
- A. The patient is experiencing intermittent waves of nausea
- B. The patient has absent breath sounds throughout the left lung.
- C. The patient has decreased bowel sounds in all four quadrants.
- D. The patient complains of 6/10 (0-10 scale) abdominal pain.
Correct Answer: B
Rationale: Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.