Nokea
The nurse is performing an assessment on a client being admitted for acute pancreatitis. Which assessment finding would support a diagnosis of acute pancreatitis?
- A. Homan's sign
- B. Cullen's sign
- C. Hyperactive bowel sounds
- D. Kernig's sign
Correct Answer: B
Rationale: Cullen's sign (B), periumbilical bruising, is associated with acute pancreatitis due to retroperitoneal hemorrhage. Homan's (A) and Kernig's (D) signs are unrelated, and bowel sounds (C) are typically hypoactive.
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The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
- A. McBurney's point tenderness is a sign of appendicitis
- B. Appendicitis is more common among males
- C. A low carbohydrate diet is a risk factor for appendicitis
- D. Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography
- E. The client may have an elevated white blood cell count (WBC)
Correct Answer: A,E
Rationale: McBurney's point tenderness (A) and elevated WBC (E) are hallmark signs of appendicitis. It is not more common in males (B), low-carb diets (C) are not a risk factor, and ERCP (D) is not used for diagnosis.
A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
- A. Slight cough after sipping water.
- B. Hoarseness of voice during speech.
- C. Reports of mild throat discomfort when swallowing.
- D. Presence of a wet, gurgling cough after drinking water.
Correct Answer: D
Rationale: A wet, gurgling cough after drinking water (D) indicates possible aspiration, requiring immediate intervention to prevent complications like pneumonia. Slight cough (A), hoarseness (B), and mild discomfort (C) are less urgent.
The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
- A. Inserting an indwelling urinary catheter.
- B. Weighing the client in the morning before the first void.
- C. Placing a mask on the client before changing the central line dressing.
- D. Establishing continuous cardiac monitoring.
Correct Answer: B
Rationale: Weighing the client daily (B) monitors fluid balance and nutritional status, critical for TPN management. Catheters (A), masks (C), and cardiac monitoring (D) are not routinely required unless indicated.
The health care provider (HCP) places an order to administer gentamicin intravenously to a client with acute diverticulitis. It is important the nurse knows that intravenous gentamicin is administered:
- A. Over one minute via IV push
- B. Over two minutes via IV push
- C. As an IV infusion over 15-20 minutes
- D. As an IV infusion over 30 minutes to two hours
Correct Answer: D
Rationale: Gentamicin (D) is administered as an IV infusion over 30 minutes to two hours to ensure safe delivery and minimize toxicity risks like nephrotoxicity.
The nurse is teaching a client about prescribed metronidazole. Which of the following statements by the client indicates effective teaching?
- A. I should not drink alcohol while I’m taking metronidazole.
- B. It is okay for me to be in the sun while I’m taking this medicine.
- C. I should take the medicine until my stomach stops hurting, then stop.
- D. I should take the medicine on an empty stomach.
Correct Answer: A
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoiding alcohol is correct. Sun exposure is not a major concern, stopping early risks incomplete treatment, and metronidazole can be taken with food.