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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 HCP writes the following admission orders for the client with possible appendicitis. Which order should the nurse question?
- A. Place on NPO (nothing per mouth) status.
- B. No analgesics until diagnosis is confirmed.
- C. Apply heat to abdomen to decrease pain.
- D. Start IV lactated Ringer’s at 125 mL/hr.
Correct Answer: C
Rationale: A. Clients are kept NPO in case surgery is needed. B. Analgesic medications are usually withheld until a definitive diagnosis is established to avoid masking critical symptom changes. C. The nurse should question applying heat to the abdomen when appendicitis is suspected. Heat is contraindicated because it increases circulation, which, in turn, could cause the appendix to rupture. D. Isotonic IV fluids are initiated to replace lost body fluid and prevent dehydration.
The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first?
- A. Ask the parent about the child's diet.
- B. Assess the child's tissue turgor.
- C. Give the child a sucker if she is good.
- D. Notify the HCP the child is waiting to be seen.
Correct Answer: B
Rationale: Assessing tissue turgor evaluates dehydration, a priority in a toddler with vomiting and diarrhea. Diet history, rewards, and HCP notification follow assessment.
The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.
The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurse’s priority when monitoring for GI bleeding?
- A. The 40-year-old client who is positive for Helicobacter pylori (H. pylori)
- B. The 45-year-old client who drinks 4 ounces of alcohol a day
- C. The 70-year-old client who takes daily baby aspirin of 81 mg
- D. The 30-year-old pregnant client taking acetaminophen prn
Correct Answer: C
Rationale: A. The presence of H. pylori has not been proven to predispose to GI bleeding. B. Although alcohol is associated with gastric mucosal injury, its causative role in bleeding is unclear. C. It is most important for the nurse to monitor the 70-year-old client who is taking aspirin. The client has two risk factors for GI bleeding: age and taking aspirin. D. Pregnancy and acetaminophen usage do not predispose to GI bleeding.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.