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The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
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The nurse is caring for clients in an outpatient clinic. Which information should the nurse teach regarding the American Cancer Society's recommendations for the early detection of colon cancer?
- A. Beginning at age 60, a digital rectal examination should be done yearly.
- B. After reaching middle age, a yearly fecal occult blood test should be done.
- C. Have a colonoscopy at age 50 and then once every five (5) to 10 years.
- D. A flexible sigmoidoscopy should be done yearly after age 40.
Correct Answer: C
Rationale: The American Cancer Society recommends a colonoscopy starting at age 45–50, then every 5–10 years for average-risk individuals, as it effectively detects polyps and cancer. Other options are outdated or incorrect.
The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
- A. Ask the client to recall what she ate for the last 24 hours.
- B. Determine what type of birth control the client has been using.
- C. Reweigh the client to confirm the data.
- D. Take the client's pulse and blood pressure.
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.
Which blood test results would confirm a diagnosis of appendicitis?
- A. WBC of 13,000
- B. RBC of 4.5 million
- C. Platelet count of 300,000
- D. Positive heterophil antibody test
Correct Answer: A
Rationale: An elevated WBC count (e.g., 13,000) indicates inflammation, supporting an appendicitis diagnosis. Normal RBC and platelet counts are not specific, and a heterophil antibody test is for infectious mononucleosis.
The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first?
- A. Check for a fecal impaction.
- B. Encourage the client to drink fluids.
- C. Check the chart for sodium and potassium levels.
- D. Apply a protective barrier cream to the perianal area.
Correct Answer: D
Rationale: Dark, watery stool risks perianal skin breakdown, so applying a barrier cream is the first intervention. Impaction is unlikely, fluids are secondary, and labs follow assessment.