Nokea
The nurse is reviewing gastrointestinal assessment with a group of student nurses. It would be correct if the student identifies which of the following would cause hyperactive bowel sounds?
- A. Paralytic ileus
- B. Gastroenteritis
- C. Late bowel obstruction
- D. Peritonitis
Correct Answer: B
Rationale: Gastroenteritis (B) causes hyperactive bowel sounds due to increased intestinal motility from inflammation or infection. Paralytic ileus (A), late bowel obstruction (C), and peritonitis (D) typically cause hypoactive or absent bowel sounds.
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A 52-year-old client with a 20-year history of alcohol abuse is hospitalized with mild ascites, jaundice, and bruising. Imaging demonstrates the presence of esophageal varices, while the client's elevated serum ammonia level indicates hepatic encephalopathy. The nurse is concerned the client's esophageal varices may rupture and proceeds to educate the client accordingly. Which item should the nurse include in the client's education session?
- A. Do not lift heavy objects.
- B. Avoid walking briskly.
- C. Avoid taking barbiturates.
- D. Avoid ingesting antacids.
Correct Answer: A
Rationale: Avoiding heavy lifting (A) reduces intra-abdominal pressure, decreasing the risk of esophageal variceal rupture. The other options are less directly related to preventing variceal bleeding.
The nurse is taking care of a client that is scheduled to undergo a gastric analysis at 8:00 AM tomorrow. Which should be included in the client's plan of care?
- A. Instruct the client that she should not eat or drink anything after midnight.
- B. Teach the client that in case she feels hungry, she can chew some gum.
- C. Instruct the client that she needs to be on bed rest for 2 hours after the procedure.
- D. Tell the client that she is allowed to smoke 1 hour prior to surgery.
Correct Answer: A
Rationale: Fasting after midnight (A) ensures accurate gastric analysis results. Chewing gum (B), bed rest (C), and smoking (D) are not appropriate.
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following complications should the nurse assess for during the therapy? Select all that apply.
- A. Hyperglycemia
- B. Infection
- C. Air embolism
- D. Cardiac tamponade
- E. Dehydration
Correct Answer: A,B,C
Rationale: TPN risks include hyperglycemia (A) from high glucose content, infection (B) due to central line use, and air embolism (C) from improper line management. Cardiac tamponade (D) and dehydration (E) are less directly associated.
The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
- A. Right upper quadrant, radiating to the right shoulder.
- B. Right upper quadrant, radiating to the left shoulder.
- C. Right lower quadrant, radiating to the pelvic bones.
- D. Right lower quadrant, radiating to the umbilicus.
Correct Answer: A
Rationale: Cholecystitis typically causes pain in the right upper quadrant radiating to the right shoulder (A) due to gallbladder inflammation and referred pain via the phrenic nerve.
The emergency department (ED) nurse reviews the client's triage note. Select the findings in the triage note that require immediate follow-up.
- A. 56-year-old male reports persistent nausea and vomiting that has not improved with prescribed anti-emetic.
- B. He reports being diagnosed with viral gastroenteritis three days ago by his physician.
- C. He states that his n/v has gotten so bad that he cannot hold down food or fluids.
- D. On assessment, the client is lethargic and oriented. Unsteady gait.
- E. He reports that he can take his prescribed medications with sips of water.
- F. On assessment, the client is lethargic and oriented. Unsteady gait.
- G. Vital signs: T 99°F (37°C), P 108, RR 18, BP 132/77, pulse oximetry reading 97% on room air.
Correct Answer: A,C,D,F
Rationale: Persistent nausea/vomiting (A, C), lethargy, and unsteady gait (D, F) suggest dehydration or electrolyte imbalances requiring immediate follow-up.