Nokea
The following scenario applies to the next 1 items
The nurse is caring for an older adult in the medical-surgical unit
Item 1 of 1
Health History
84-year-old female was admitted to the medical-surgical unit with a three-day history of abdominal pain, distention, nausea, and persistent vomiting. She reports that she has not had a bowel movement in five days and has no appetite.
Vital Signs
Oral temperature 101.1° F (38.3° C)
Pulse 108/minute
Respirations 22/minute
Blood pressure 100/64 mm Hg
Oxygen saturation 96% on room air.
The nurse reviews the client's health history and vital signs. Click to specify if the findings are consistent with a small bowel obstruction or appendicitis. Each row must have at least one but may have more than one response option selected.
- A. Unable to pass stool
- B. Fever
- C. Distended abdomen
- D. Right lower quadrant abdominal pain
- E. Nausea and vomiting
Correct Answer: A,B,C,E;A,B,C,D,E
Rationale: Small bowel obstruction: A (Unable to pass stool), B (Fever), C (Distended abdomen), E (Nausea and vomiting). Appendicitis: A, B, C, D (Right lower quadrant abdominal pain), E. Both conditions can present with these symptoms, though right lower quadrant pain is more specific to appendicitis.
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The following scenario applies to the next 6 items
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 1 of 6
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.
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
The nurse is reviewing the client's admission information. Select the findings that require immediate follow-up.
- A. The client reports sudden severe epigastric pain radiating to the back.
- B. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension.
- C. His home medications include pantoprazole and lisinopril.
- D. Upon assessment, the client is noted to be alert and oriented x 4.
- E. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10.
- F. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea.
- G. 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.
Correct Answer: A,E,G
Rationale: Severe epigastric pain radiating to the back (A), nausea and vomiting worsened by fatty foods (E), and vital sign abnormalities (G) such as fever, tachycardia, and hypotension suggest acute pancreatitis, requiring urgent follow-up.
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.
The following scenario applies to the next 1 items
The nurse is caring for a client immediately following an abdominal paracentesis
Item 1 of 1
Procedure Note
1845 - Emergency ultrasound-guided abdominal paracentesis was performed because the client presented with labored respirations, dyspnea, abdominal cramping, and overall discomfort. Informed consent was obtained, and the client agreed to the procedure. Prior to the procedure, the client emptied their bladder. The site was cleaned and numbed with 1% lidocaine, and using an aseptic technique and an ultrasound; a 14-gauge catheter was inserted to remove 10 mL of clear ascitic fluid. Subsequently, the fluid was drained via tubing. 6 liters of fluid were removed. The client tolerated the procedure well and reported immediate relief in the dyspnea and abdominal cramping following the procedure.
Immediately following this procedure, the nurse should monitor the client's ............. because the client has the risk of ........... If the client should experience this immediate post-procedure complication, the nurse should anticipate a prescription for ........
- A. Blood pressure
- B. Urinary output
- C. Hypotension
- D. Peritonitis
- E. Albumin
- F. Ceftriaxone
Correct Answer: A,C,E
Rationale: Monitor blood pressure (A) for hypotension (C) due to fluid shifts post-paracentesis. Albumin (E) is anticipated to restore intravascular volume if hypotension occurs.
The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?
- A. Decreased abdominal cramping
- B. Absence of nausea and vomiting
- C. Decreased urinary retention
- D. Less burning with urination
Correct Answer: A
Rationale: Dicyclomine, an anticholinergic, reduces intestinal spasms, so decreased abdominal cramping indicates a therapeutic response. It is not primarily for nausea, urinary retention, or dysuria.
The nurse is caring for an undernourished client who recently began receiving total parenteral nutrition (TPN). Which laboratory value would indicate that the client is responding to treatment?
- A. Fasting blood glucose: 129 mg/dL (7.15 mmol/L) [70-110 mg/dL, 4.0–6.0 mmol/L]
- B. White blood cell (WBC) count: 12,000 mm3 (0.012×10⁹/L) [4,000-11,000 cells/µL,3.5–10.5 × 10⁹/L]
- C. Albumin: 3.6 g/dL [3.5-5 g/dL]
- D. Urine specific gravity: 1.040 [1.005-1.030]
Correct Answer: C
Rationale: Albumin within the normal range (3.6 g/dL) indicates improved nutritional status, a goal of TPN. Elevated glucose, WBC, and urine specific gravity suggest other issues (e.g., hyperglycemia, infection, dehydration) not directly related to TPN’s therapeutic effect.