Nokea
The nurse is caring for clients on a surgical unit. Which client should the nurse assess first?
- A. The client who had an inguinal hernia repair and has not voided in four (4) hours.
- B. The client who was admitted with abdominal pain who suddenly has no pain.
- C. The client four (4) hours postoperative abdominal surgery with no bowel sounds.
- D. The client who is one (1) day postappendectomy and is being discharged.
Correct Answer: B
Rationale: Sudden resolution of abdominal pain may indicate perforation (e.g., appendicitis), a life-threatening emergency requiring immediate assessment. Urinary retention, absent bowel sounds, and discharge are less urgent.
You may also like to solve these questions
The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis?
- A. Decreased gurgling sounds on auscultation of the abdominal wall.
- B. A hard, firm, edematous abdomen on palpation.
- C. Frequent, small melena-type liquid bowel movements.
- D. Bowel assessment reveals loud, rushing bowel sounds.
Correct Answer: D
Rationale: Loud, rushing bowel sounds are expected in gastroenteritis due to increased peristalsis from irritation. Decreased sounds, hard abdomen, or melena suggest other conditions.
The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet?
- A. It's a good thing I gave up drinking alcohol last year.'
- B. I will have to drink lots of milk and cream every day.'
- C. I will stay away from cola drinks after I am discharged.'
- D. Eating three nutritious meals and snacks every day is okay.'
Correct Answer: B
Rationale: Milk and cream cause rebound acidity and are not recommended for ulcer clients. Avoiding alcohol and cola, and eating regular meals and snacks, are appropriate.
The male client had abdominal surgery and the nurse suspects the client has peritonitis. Which assessment data support the diagnosis of peritonitis?
- A. Absent bowel sounds and potassium level of 3.9 mEq/L.
- B. Abdominal cramping and hemoglobin of 14 g/dL.
- C. Profuse diarrhea and stool specimen shows Campylobacter.
- D. Hard, rigid abdomen and white blood cell count 22,000/mm3.
Correct Answer: D
Rationale: A hard, rigid abdomen and elevated WBC count (22,000/mm3) indicate peritonitis due to peritoneal inflammation and infection. Absent bowel sounds are nonspecific, cramping with normal hemoglobin is less indicative, and diarrhea with Campylobacter suggests gastroenteritis.
The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?
- A. “My cirrhosis was caused from too much alcohol; I plan to stop drinking.”
- B. “I need to rest more; I plan on only going to work on a part-time basis.”
- C. “Propranolol has been ordered to decrease my blood pressure.”
- D. “Furosemide will help to reduce the amount of abdominal fluid.”
Correct Answer: C
Rationale: A. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client’s diet. B. Rest may enable the liver to restore itself and should be encouraged. C. Although propranolol (Inderal) does decrease BP, it is not ordered for this purpose in treating cirrhosis. Prophylactic treatment with a nonselective beta blocker like propranolol has been shown to reduce the risk of bleeding from esophageal varices and to reduce bleeding-related deaths. D. Furosemide (Lasix) is used in combination with potassium-sparing diuretics to decrease ascites.