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.
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The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
Which statement by the client diagnosed with hepatitis warrants immediate intervention by the clinic nurse?
- A. I will not drink any type of beer or mixed drink.
- B. I will get adequate rest so I don’t get exhausted.
- C. I had a big hearty breakfast this morning.
- D. I took some cough syrup for this nasty head cold.
Correct Answer: D
Rationale: Cough syrup may contain hepatotoxic ingredients (e.g., acetaminophen), posing a risk to a hepatitis patient’s liver, requiring immediate intervention. Other statements are appropriate or benign.
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.