Nokea
The nurse is preparing to admit the hospitalized client diagnosed with peritonitis. Which collaborative interventions should the nurse anticipate? Select all that apply.
- A. Intravenous (IV) fluids
- B. Oral or IV antibiotics
- C. NPO (nothing per mouth) status
- D. Analgesic medications
- E. Positioning in a supine position
- F. Nasogastric tube (NGT) to suction
Correct Answer: A,C,D,F
Rationale: IV fluids are given to replace fluids shifting in the peritoneum and bowel from the inflammatory process. NPO status will rest the bowel. Analgesics are utilized for pain control. NG suction decompresses the stomach and intestine and rests the GI tract.
You may also like to solve these questions
The nurse is assessing a client complaining of abdominal pain. Which data support the diagnosis of a bowel obstruction?
- A. Steady, aching pain in one specific area.
- B. Sharp back pain radiating to the flank.
- C. Sharp pain increases with deep breaths.
- D. Intermittent colicky pain near the umbilicus.
Correct Answer: D
Rationale: Intermittent colicky pain near the umbilicus is characteristic of bowel obstruction due to peristalsis against the blockage. Steady pain, back pain, and pain with breathing suggest other conditions.
The client is prescribed infliximab 5 mg/kg every 8 weeks for treatment of Crohn’s disease. The client weighs 116 lb. How many milligrams (mg) should the nurse administer? _________ mg (Record your answer rounded to a whole number.)
Correct Answer: 264
Rationale: To calculate the dose: 1. Convert weight to kilograms: 116 lb ÷ 2.2 = 52.727 kg. 2. Calculate dose: 5 mg/kg × 52.727 kg = 263.635 mg. 3. Round to a whole number: 264 mg.
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Check the abdominal dressings for bleeding.
- B. Increase the IV fluid if the blood pressure is low.
- C. Ambulate the client to the bathroom.
- D. Auscultate the breath sounds in all lobes.
Correct Answer: C
Rationale: Ambulating the client is within the UAP’s scope, promoting recovery. Checking dressings, adjusting IV fluids, and auscultating breath sounds require RN assessment skills.
During a health promotion seminar for senior citizens, a participant asks the nurse to discuss symptoms of gastric cancer. Which statement should be the basis for the nurse’s response?
- A. Cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients.
- B. Pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists.
- C. Unexplained weight gain and increased body mass index (BMI) are early symptoms of gastric cancer.
- D. Anemia is uncommon in gastric cancer, but if it occurs, it is likely due to the effects of aging.
Correct Answer: A
Rationale: A. Eighty percent of clients with early gastric cancer do not have symptoms. B. Pain caused by gastric cancer can be alleviated by OTC histamine receptor antagonists. C. Weight loss and anemia are common symptoms, not weight gain and increased BMI. D. Anemia occurs from malabsorption and nutritional deficiencies, not the effects of aging.
The nurse is caring for an elderly client diagnosed with acute gastritis. Which client problem is priority for this client?
- A. Fluid volume deficit.
- B. Altered nutrition: less than body requirements.
- C. Impaired tissue perfusion.
- D. Alteration in comfort.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in elderly clients with acute gastritis due to vomiting/diarrhea, risking dehydration. Nutrition, perfusion, and comfort are secondary.