Nokea
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
- A. I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish.
- B. I should slowly introduce high-fiber foods in my diet.
- C. I must always wear a pouch over my stoma.
- D. I should clean the skin around my stoma with rubbing alcohol.
Correct Answer: D
Rationale: Using rubbing alcohol (D) can irritate the skin around the stoma. Options A, B, and C are appropriate for colostomy care.
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The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet.
- B. Peritonitis, diverticulitis, appendicitis, gastroenteritis.
- C. Lung sounds, pulse, temperature, hemoglobin and hematocrit.
Correct Answer: B: Appendicitis; A: Insert a peripheral VAD, prepare the client for surgery; C: Temperature, pulse
Rationale: The clinical presentation (right lower quadrant pain, fever, leukocytosis, rigid abdomen) strongly suggests appendicitis (B). Inserting a VAD and preparing for surgery (A) are critical for anticipated appendectomy. Monitoring temperature and pulse (C) tracks infection and hemodynamic status.
The following scenario applies to the next 1 items.
The nurse is caring for a 44-year-old male with abdominal pain and persistent nausea/vomiting.
Item 1 of 1
History of Present Illness
Abdominal pain that started one day ago following heavy alcohol use. The pain is localized to the epigastric region. Persistent nausea and vomiting were reported. Physical exam showed ecchymosis around the umbilicus and tenderness upon palpation.
Vital Signs
• Oral temperature 99.0° F (37° C)
• Pulse 119
• Respirations 22
• BP 90/58
• Pulse oximetry 95% on room air
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two priority actions the nurse should take to address that condition, and two priority parameters the nurse should monitor to assess the client's progress.
- A. Obtain a prescription of 0.9% saline bolus, Inquire about the clients alcohol drinking habits, Obtain a prescription for regular insulin, Establish peripheral intravenous (IV) access, Transport the client for an abdominal computed tomography (CT) scan.
- B. Acute Pancreatitis, Peptic Ulcer Disease, Diverticulitis, Peritonitis, Gastroenteritis.
- C. Level of Consciousness (LOC), Bowel Sounds, Vital Signs, Serum Glucose Level, Daily Weights.
Correct Answer: B: Acute Pancreatitis; A: Obtain a prescription of 0.9% saline bolus, Establish peripheral IV access; C: Vital Signs, Level of Consciousness
Rationale: Epigastric pain, nausea/vomiting, and periumbilical ecchymosis suggest acute pancreatitis (B). Saline bolus and IV access (A) address hypovolemia. Monitoring vital signs and LOC (C) tracks hemodynamic stability and complications.
A nurse is caring for a 57 year old client and is teaching them about screening for colorectal cancer. Which of the following information should the nurse include?
- A. It is recommended that colon cancer screening with a colonoscopy should begin at age 45.
- B. It is recommended that colon cancer screening with a colonoscopy should begin at age 70.
- C. It is recommended that colon cancer screening with a colonoscopy should begin at age 40.
- D. It is recommended that colon cancer screening with a colonoscopy should begin at age 65.
Correct Answer: A
Rationale: Current guidelines recommend colonoscopy screening for colorectal cancer starting at age 45 (A) for average-risk individuals.
The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. Pantoprazole
- B. Ciprofloxacin
- C. Lactulose
- D. Loperamide
Correct Answer: B
Rationale: Ciprofloxacin, an antibiotic, is used to treat bacterial peritonitis. Pantoprazole reduces acid, lactulose treats hepatic encephalopathy, and loperamide slows motility, none of which address peritonitis directly.
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.