Nokea
The nurse is teaching a client about newly prescribed metoclopramide for nausea and vomiting. Which adverse reaction requires immediate follow-up?
- A. Dystonia
- B. Fever
- C. Drowsiness
- D. Diarrhea
Correct Answer: A
Rationale: Dystonia, an extrapyramidal symptom, is a serious adverse effect of metoclopramide requiring immediate follow-up due to its impact on movement. Fever, drowsiness, and diarrhea are less urgent side effects.
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The nurse is caring for a client who is newly prescribed cimetidine. The nurse understands that this medication is prescribed to treat which condition?
- A. Cystic fibrosis
- B. Clostridium difficile
- C. H. pylori infection
- D. Crohn’s disease
Correct Answer: C
Rationale: Cimetidine, an H2 receptor blocker, is used in H. pylori infection to reduce gastric acid, aiding in ulcer healing alongside antibiotics. It is not indicated for cystic fibrosis, C. difficile, or Crohn’s disease.
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.
The nurse is caring for a client who is postprocedure following an endoscopy. Which priority action should the nurse take prior to resuming the client's diet?
- A. Assess the client's oxygenation level
- B. Assess for the return of the client's gag reflex
- C. Have the healthcare provider speak with the client regarding results of the procedure
- D. Start with a soft diet to see if the client will tolerate
Correct Answer: B
Rationale: Assessing the gag reflex (B) ensures safe swallowing post-endoscopy to prevent aspiration before resuming the diet.
The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order?
- A. Cyanocobalamin
- B. Metoclopramide
- C. Sucralfate
- D. Hydroxyzine
Correct Answer: A
Rationale: Cyanocobalamin (A) is anticipated post-gastrectomy to prevent vitamin B12 deficiency due to reduced intrinsic factor production.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.
Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air
Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia
Which assessment findings require follow-up? Select all that apply.
- A. Jaundice
- B. Labored breathing
- C. Hypoactive bowel sounds
- D. Respiratory rate
- E. Oral temperature
- F. Yellow sclera
Correct Answer: B,D,E
Rationale: Labored breathing (B), elevated respiratory rate (D), and fever (E) indicate potential complications like infection or respiratory compromise in liver cirrhosis, requiring urgent follow-up. Jaundice and yellow sclera (A, F) are expected, and hypoactive bowel sounds (C) are less urgent.