Nokea
The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
- A. No bowel movement.
- B. Oxygen saturation 96%.
- C. Vital signs within normal baseline.
- D. Intact gag reflex.
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
You may also like to solve these questions
Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
- A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
- B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
- C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
- D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Correct Answer: D
Rationale: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.