Nokea
The parents of a female toddler bring the child to the pediatrician's office with nausea, vomiting, and diarrhea. Which intervention should the nurse implement first?
- A. Ask the parent about the child's diet.
- B. Assess the child's tissue turgor.
- C. Give the child a sucker if she is good.
- D. Notify the HCP the child is waiting to be seen.
Correct Answer: B
Rationale: Assessing tissue turgor evaluates dehydration, a priority in a toddler with vomiting and diarrhea. Diet history, rewards, and HCP notification follow assessment.
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The client with Crohn’s disease has undergone a barium enema that showed strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of which complication?
- A. Peritonitis
- B. Obstruction
- C. Malabsorption
- D. Fluid imbalance
Correct Answer: B
Rationale: A. Peritonitis would not be an expected consequence of a bowel stricture. B. The nurse should monitor for signs of a bowel obstruction. Bowel strictures are a common complication of Crohn’s disease and can result in an acute bowel obstruction. C. Malabsorption would not be an expected consequence of a bowel stricture. D. Fluid balance would be affected once total obstruction develops.
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.
The emergency department nurse is working in a community hospital. During the past two (2) hours, 15 clients have been admitted with Salmonella food poisoning. Which information should the nurse discuss with the clients?
- A. Explain the incubation period is 48 to 72 hours.
- B. Explain the source of this poisoning is contaminated water.
- C. Explain the sources of contamination are eggs and chicken.
- D. Explain the bacterial contaminant came from canned foods.
Correct Answer: C
Rationale: Salmonella is commonly associated with undercooked eggs and poultry, making this the most accurate information. Incubation is 6–72 hours, water is less common, and canned foods are linked to botulism.
The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication?
- A. It prevents the final transport of hydrogen ions into the gastric lumen.
- B. It blocks receptors controlling hydrochloric acid secretion by the parietal cells.
- C. It protects the ulcer from the destructive action of the digestive enzyme pepsin.
- D. It neutralizes the hydrochloric acid secreted by the stomach.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) inhibit the H+/K+ ATPase pump, preventing hydrogen ion transport into the gastric lumen, thus reducing acid production to promote ulcer healing. Blocking receptors is for H2 antagonists, pepsin protection is for mucosal agents, and neutralization is for antacids.
The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?
- A. Pain related to heartburn from gastric reflux.
- B. Aspiration related to regurgitation of food accumulated in the diverticula.
- C. Constipation related to anatomical changes of the sigmoid colon.
- D. Altered nutrition, less than body requirements related to dysphagia.
Correct Answer: B
Rationale: A. The client may have difficulty with heartburn, but this does not take priority over aspiration. B. Zenker’s diverticulum is an outpouching of the esophagus near the hypopharyngeal sphincter. Food can become trapped in the diverticula and cause aspiration. C. Constipation is not a concern with Zenker’s diverticulum. D. The client may have weight loss, but this does not take priority over aspiration.