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The nurse is caring for clients on a medical unit. Which client information should be brought to the attention of the HCP immediately?
- A. A serum sodium of 128 mEq/L in a client diagnosed with obstipation.
- B. The client diagnosed with fecal impaction who had two (2) hard formed stools.
- C. A serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea.
- D. The client with diarrhea who had two (2) semiliquid stools totaling 300 mL.
Correct Answer: A
Rationale: Hyponatremia (sodium 128 mEq/L) in obstipation risks neurological complications, requiring immediate HCP attention. Formed stools, normal potassium, and moderate diarrhea are less urgent.
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The client has had a liver biopsy. Which postprocedure intervention should the nurse implement?
- A. Instruct the client to void immediately.
- B. Keep the client NPO for eight (8) hours.
- C. Place the client on the right side.
- D. Monitor blood urea nitrogen (BUN) and creatinine level.
Correct Answer: C
Rationale: Placing the client on the right side applies pressure to the biopsy site, reducing bleeding risk. Voiding, NPO status, and BUN/creatinine are not specific to liver biopsy care.
The client is diagnosed with an acute exacerbation of inflammatory bowel disease (IBD). Which food selection would be the best choice for a meal?
- A. Roast beef on wheat bread and a milk shake.
- B. Hamburger, french fries, and a cola.
- C. Pepper steak, brown rice, and iced tea.
- D. Roasted turkey, instant mashed potatoes, and water.
Correct Answer: D
Rationale: Roasted turkey, instant mashed potatoes, and water are low-residue, easy-to-digest foods suitable for acute IBD exacerbation. Other options are high-fiber or irritating.
While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications?
- A. Alteration in bowel elimination patterns.
- B. Knowledge deficit in the causes of ulcers.
- C. Inability to cope with changing family roles.
- D. Potential for alteration in gastric emptying.
Correct Answer: A
Rationale: Peptic ulcer disease can lead to complications like bleeding or perforation, which alter bowel elimination patterns (e.g., melena or hematochezia). Knowledge deficits and coping issues are psychosocial, and gastric emptying is less commonly affected.
The nurse is caring for the client to manage and decrease the sensation of nausea. Which nonpharmacological intervention should the nurse recommend?
- A. Sipping tea made from gingerroot
- B. Changing positions more rapidly
- C. Decreasing intake of solid food
- D. Playing stimulating classical music
Correct Answer: A
Rationale: A. Ginger has demonstrated antiemetic properties as well as analgesic and sedative effects on GI motility. B. Avoidance of sudden changes in position and decreasing activity are recommended to control nausea. C. All food should be stopped when nausea is present to prevent stomach stretching and stimulation of the afferent nerve fibers. D. A quiet, calm environment, rather than one that is stimulating, is recommended to decrease nausea.