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The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.
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The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?
- A. Bowel sounds auscultated 15 times in one (1) minute.
- B. Belching after eating a heavy and fatty meal late at night.
- C. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.
- D. A decreased frequency of distress located in the epigastric region.
Correct Answer: C
Rationale: A 20 mm Hg drop in systolic BP on positional change suggests orthostatic hypotension, possibly from bleeding, requiring immediate intervention. Normal bowel sounds, belching, and reduced pain are less concerning.
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.
The nurse is admitting the client for a colonoscopy. Which information, if found in the client’s medical record, should the nurse consider as the primary reason for this client’s colonoscopy?
- A. Chronic constipation
- B. Urostomy placed 3 years ago
- C. History of colon polyps
- D. Hemoglobin 10 g/dL
Correct Answer: C
Rationale: A. Although a colonoscopy may be performed to evaluate chronic constipation, this is less likely than evaluation of colon polyps. B. A urostomy is used for urinary diversion following bladder cancer; it does not affect the colon. C. Colonoscopy is used in screening and diagnosing colon cancer and for surveillance in persons with prior history of colon cancer or polyps. This is likely the primary reason for a colonoscopy with this client. D. An Hgb of 10 g/dL is slightly low. This could be a reason for a colonoscopy, especially if there is a pattern of low Hgb levels and the stool guaiac test is positive. However, this is less likely the primary reason than evaluation of colon polyps.
The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy?
- A. Gastrointestinal bleeding.
- B. Hypoalbuminemia.
- C. Splenomegaly.
- D. Hyperaldosteronism.
Correct Answer: A
Rationale: GI bleeding increases ammonia levels (from blood protein breakdown), a key trigger for hepatic encephalopathy. Other complications are less directly linked to this risk.
Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
- A. Assess the client's neurological status.
- B. Prepare to administer a loop diuretic.
- C. Check the client's stool for blood.
- D. Assess for an abdominal fluid wave.
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.