Nokea
The nurse is preparing a client diagnosed with GERD for surgery. Which information warrants notifying the HCP?
- A. The client's Bernstein esophageal test was positive.
- B. The client's abdominal x-ray shows a hiatal hernia.
- C. The client's WBC count is 14,000/mm3.
- D. The client's hemoglobin is 13.8 g/dL.
Correct Answer: C
Rationale: An elevated WBC count (14,000/mm3) suggests infection or inflammation, which could complicate surgery and requires immediate attention. A positive Bernstein test and hiatal hernia are expected in GERD, and a hemoglobin of 13.8 g/dL is within normal limits.
You may also like to solve these questions
The client of Chinese ethnicity has diarrhea and refuses to drink the prescribed oral hydration solution, insisting on having chicken broth instead. Which statement about clients of Chinese ethnicity should be the basis for the nurse’s intervention in this situation?
- A. They consider chicken a food with yang qualities.
- B. They believe extra protein is needed to treat diarrhea.
- C. They believe high-sodium foods are needed to treat diarrhea.
- D. They mistrust modern medicine and eat broth to treat disease.
Correct Answer: A
Rationale: A. Loose stools are a yin symptom, which should be treated with foods that have yang qualities, one of which is chicken. B. There is no belief in the Chinese culture related to consuming high-protein foods. C. There is no belief in the Chinese culture related to consuming high-sodium foods. D. The Chinese do not mistrust modern medicine but may combine Western medicine and Chinese herbal medicines to treat disease.
The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
The client with a duodenal ulcer is ready for discharge. Which statement made by the client indicates a need for more teaching about his diet?
- A. It's a good thing I gave up drinking alcohol last year.'
- B. I will have to drink lots of milk and cream every day.'
- C. I will stay away from cola drinks after I am discharged.'
- D. Eating three nutritious meals and snacks every day is okay.'
Correct Answer: B
Rationale: Milk and cream cause rebound acidity and are not recommended for ulcer clients. Avoiding alcohol and cola, and eating regular meals and snacks, are appropriate.
Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications?
- A. Alteration in bowel elimination patterns.
- B. Knowledge deficit in the causes of ulcers.
- C. Inability to cope with changing family roles.
- D. Potential for alteration in gastric emptying.
Correct Answer: A
Rationale: Peptic ulcer disease can lead to complications like bleeding or perforation, which alter bowel elimination patterns (e.g., melena or hematochezia). Knowledge deficits and coping issues are psychosocial, and gastric emptying is less commonly affected.
The nurse is caring for the newly admitted client with acute necrotizing pancreatitis. Which interventions, if prescribed, should the nurse implement?
- A. NS 1000 mL IV over 1 hour, then IV fluids at 250 mL/hour
- B. Initiate nasojejunal enteral feedings with a low-fat formula
- C. Imipenem-cilastatin 500 mg IV every 6 hours
- D. Up to chair for meals and ambulate four times daily
- E. Position left side-lying with head of bed elevated 30 degrees
- F. Insert a urinary catheter; monitor urine output every 2 hours
Correct Answer: A, B, C, F
Rationale: Giving an IV bolus followed by fluids at 250 mL/hour should be implemented. A large amount of fluids is lost due to third spacing into the retroperitoneum and intraabdominal area. Fluids are needed to prevent hypovolemia and maintain hemodynamic stability. B. Nasojejunal enteral feedings with a low-fat formula should be initiated to decrease the secretion of secretin, meet calorie needs, and maintain a positive nitrogen balance. C. Antibiotics, usually medications of the imipenem class such as imipenem-cilastatin (Primaxin), are used when pancreatitis is complicated by infected pancreatic necrosis. They have greater potency and a broader antimicrobial spectrum than other beta-lactam antibiotics. D. The client should be maintained on bedrest to decrease the metabolic rate and therefore reduce pancreatic secretions. E. Discomfort frequently improves with the client in the supine position rather than side-lying. F. A urinary catheter should be inserted to closely monitor urine output for circulating fluid volume status and to monitor for complications.