Nokea
The nurse is obtaining a health history on a client in the medical clinic. The client states, 'I think I have an ulcer.' Which of the following responses by the nurse is BEST?
- A. Do you have a burning pain in the epigastric region?
- B. Do you have sharp pain in your lower abdomen?
- C. Do you have right shoulder pain with vomiting?
- D. Do you have heartburn when you lie down?
Correct Answer: A
Rationale: Burning epigastric pain is a classic ulcer symptom, guiding further assessment. Options B, C, and D suggest other conditions.
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The nurse is making patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor?
- A. A client one-day postoperative after an appendectomy.
- B. A client who had a detached retina surgically repaired 4 hours ago.
- C. A client with a Sengstaken-Blakemore tube in place.
- D. A client two-days postoperative after a laminectomy with spinal fusion.
Correct Answer: A
Rationale: stable patient with expected outcome
An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP?
- A. Administer a cathartic enema to cleanse the bowel.
- B. Obtain information about client allergies.
- C. Instruct the client to be NPO after midnight.
- D. Teach the client that x-rays will be taken at multiple intervals.
Correct Answer: B
Rationale: assessment, clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV
The nurse is leading a class for expectant mothers.
Which of the following comments would indicate to the nurse that a pregnant woman understands the recommended dietary caloric increase for pregnancy?
- A. I will need to double my calorie intake since I am now eating for two of us.'
- B. I can add an additional 500 calories by drinking milkshakes.'
- C. I need to add 300 calories by increasing my intake of the four basic food groups.'
- D. I really need to watch my calorie intake so I will not gain too much weight.'
Correct Answer: C
Rationale: Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct-recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
- A. Which finding indicates a possible complication in a 23-year-old woman at 32-weeks gestation?
- B. The client’s urine Test is positive for glucose and acetone.
- C. The client has 1+ pedal edema in both feet at the end of the day.
- D. The client complains of an increase in vaginal discharge.
- E. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: Glucose and acetone in urine suggest possible gestational diabetes, which can lead to placental insufficiency and fetal complications, requiring immediate evaluation. Mild edema, increased vaginal discharge, and diaphragmatic pressure are common in late pregnancy and not necessarily indicative of complications.
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished