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The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.
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The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
Which gastrointestinal assessment data should the nurse expect to find when assessing the client in end-stage liver failure?
- A. Hypoalbuminemia and muscle wasting.
- B. Oligomenorrhea and decreased body hair.
- C. Clay-colored stools and hemorrhoids.
- D. Dyspnea and caput medusae.
Correct Answer: A
Rationale: Hypoalbuminemia and muscle wasting are common in end-stage liver failure due to impaired protein synthesis and malnutrition. Other options include less specific or unrelated findings.
The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering?
- A. Administer total parenteral nutrition.
- B. Maintain NPO and nasogastric tube.
- C. Maintain on a high-fiber diet and increase fluids.
- D. Obtain consent for abdominal surgery.
Correct Answer: B
Rationale: NPO status and an NG tube rest the bowel, reducing inflammation in acute diverticulitis. TPN is rare, high-fiber diets are for stable diverticulosis, and surgery is reserved for complications.
The nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfunction. Which dietary modifications should be included in the plan of care?
- A. Allow any of the client's favorite foods as long as the amount is limited.
- B. Have the client perform eructation exercises several times a day.
- C. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes.
- D. Encourage the client to consume a glass of red wine with one (1) meal a day.
Correct Answer: C
Rationale: Eating small, frequent meals reduces stomach distension, which can trigger reflux, and limiting fluids during meals prevents excessive gastric volume. Favorite foods may include triggers, eructation exercises are not standard, and alcohol like red wine can worsen GERD.
The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse?
- A. The client has 20 bloody stools a day.
- B. The client's oral temperature is 99.8°F.
- C. The client's abdomen is hard and rigid.
- D. The client complains of urinating when coughing.
Correct Answer: C
Rationale: A hard, rigid abdomen suggests peritonitis or perforation, a life-threatening complication of ulcerative colitis requiring immediate intervention. Frequent bloody stools are expected, low-grade fever is less urgent, and urinary incontinence is unrelated.