Nokea
The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include?
- A. You should take aspirin if you have mild aches or pains.
- B. You will need to consume liquids one hour after each meal.
- C. It will be important to reduce the stress in your life.
- D. Take your prescribed omeprazole with food.
Correct Answer: C
Rationale: Stress reduction (C) helps manage peptic ulcer disease by reducing acid secretion. Aspirin (A) worsens ulcers, liquids with meals (B) are not restricted, and omeprazole (D) is taken before meals.
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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 emergency department (ED) nurse is caring for a 45-year-old male client.
Item 6 of 6
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
1030: Client receiving LR at 150 mL/hr, calcium replacement completed. Urine output over the last 4 hours is 80 mL of dark amber urine. The client reports increased thirst. The abdomen continues to be distended with diminished bowel sounds. He reports that nausea has improved after receiving PRN medication. Increased edema noted in the lower extremities.
Orders
0630
• Ondansetron 4mg IV q6h PRN
• Calcium gluconate 2g IV over 5-10 minutes
• Lactated Ringer’s solution continuous infusion IV rate of 150mL/hr
The nurse knows that the client's condition is improving when they report a reduction in [condition].
- A. Urine output
- B. Pain
- C. Muscle strength
- D. None of the above
Correct Answer: B
Rationale: A reduction in pain (B) indicates improvement in acute pancreatitis as inflammation subsides. Reduced urine output (A) or muscle strength (C) would not reflect improvement.
The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.
- A. Request an order for an antibiotic
- B. Notify the physician
- C. Ambulate the client to the bedside chair
- D. Obtain an order for blood cultures
- E. Increase the nasal cannula oxygen to 4 L/minute
Correct Answer: A,B,D
Rationale: Fever, erythema, and purulent drainage suggest infection, requiring notifying the physician (B), requesting antibiotics (A), and obtaining blood cultures (D). Ambulation (C) and increasing oxygen (E) are not indicated.
The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected?
- A. Stools that contain blood and mucus
- B. Pain with urination
- C. Episodic upper abdominal pain
- D. Hypoactive bowel sounds
Correct Answer: C
Rationale: Episodic upper abdominal pain (C), often in the right upper quadrant, is a hallmark of acute cholecystitis due to gallbladder inflammation.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
- A. Supine
- B. Right lateral
- C. Sitting position with legs dangling off the edge of the bed
- D. Left lateral
Correct Answer: B
Rationale: Right lateral positioning (B) applies pressure to the biopsy site, minimizing bleeding risk post-liver biopsy.