Nokea
The nurse is instructing the client who was newly diagnosed with peptic ulcers. Which of the following diagnostic studies would the nurse anticipate reviewing with the client?
- A. A complete blood count including differential
- B. Serum antibodies for H. pylori
- C. A sigmoidoscopy
- D. Gastric analysis
Correct Answer: B
Rationale: Helicobacter pylori, a bacterium, is believed to be responsible for the majority of peptic ulcers. Blood tests are used to determine whether there are antibodies to H. pylori in the blood. A complete blood count with differential can indicate bleeding and infection associated with a bleeding ulcer. A sigmoidoscopy assesses the lower gastrointestinal tract. Gastric analysis is more common in analyzing gastric fluid in determining problems with the secretory activity of the gastric mucosa.
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The nurse is preparing to examine the abdomen of a client with reports of nausea and vomiting. What action would the nurse perform first?
- A. Palpation
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: When assessing the abdomen, the nurse would first inspect or observe the abdomen. This would be followed by auscultation, percussion, and lastly, palpation.
The nurse is providing care to a client who has had a percutaneous liver biopsy. For what would the nurse monitor the client?
- A. Signs and symptoms of bleeding
- B. Return of the gag reflex
- C. Passage of stool
- D. Intake and output
Correct Answer: A
Rationale: A major complication after a liver biopsy is bleeding, so it would be important for the nurse to monitor the client for signs and symptoms of bleeding. Return of the gag reflex would be important for the client who had an esophagogastroduodenoscopy to prevent aspiration. Monitoring the passage of stool would be important for a client who had a barium enema or colonoscopy. Monitoring intake and output is a general measure indicated for any client. It is not specific to a liver biopsy.
The nurse is caring for a client following a colonoscopy. During the procedure, two medium-sized polyps were removed. Which nursing assessment in the recovery area is a priority?
- A. Assessment of level of consciousness
- B. Hemoccult test of stool
- C. Vital signs
- D. Ability to tolerate liquids
Correct Answer: C
Rationale: The nurse is correct in assessing vital signs following a colonoscopy with polyp removal as a priority. Vital signs of an increased pulse rate and falling blood pressure can indicate a perforation and bleeding. If a perforation occurs and is not addressed at an early stage, the client's level of consciousness can become affected. There would be no reliable stool present in the bowel to Hemoccult test due to the cleansing agent and potential bleeding from the polyp removal. The ability to tolerate fluids relates to the sedation process and is not as high of a priority.
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
- A. The sclera
- B. The gums
- C. The hands
- D. The nails
- E. The hard palate
- F. The conjunctiva
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
A client is scheduled for an esophagogastroduodenoscopy (EGD) to detect lesions in the gastrointestinal tract. The nurse would observe for which of the following while assessing the client during the procedure?
- A. Signs of perforation
- B. Client's ability to retain the barium
- C. Client's tolerance for pain and discomfort
- D. Gag reflex
Correct Answer: C
Rationale: The nurse must assess the client's tolerance for pain and discomfort during the procedure. The nurse should assess the signs of perforation and the gag reflex after the procedure of EGD and not during the procedure. Assessing the client's level for retaining barium is important for a diagnostic test that involves the use of barium. EGD does not involve the use of barium.