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The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.
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Which nursing interventions should be included in the care plan for the 84-year-old client diagnosed with acute gastroenteritis?
- A. Assess the skin turgor on the back of the client’s hands.
- B. Monitor the client for orthostatic hypotension.
- C. Record the frequency and characteristics of sputum.
- D. Use Standard Precautions when caring for the client.
- E. Institute safety precautions when ambulating the client.
Correct Answer: A,B,D,E
Rationale: Assessing skin turgor and orthostatic hypotension monitors dehydration, Standard Precautions prevent spread, and safety precautions address weakness in the elderly. Sputum is unrelated to gastroenteritis.
Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.
The nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?
- A. Provide a diet that is low in residue
- B. Check the colostomy bag for stool amount
- C. Assess the perineal dressing for drainage
- D. Encourage the client to see the colostomy site
Correct Answer: C
Rationale: The perineal incision must be examined frequently to assess for drainage and the need for dressing changes.
The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia?
- A. The client jogs two (2) miles a day.
- B. The client has not gained weight.
- C. The client's teeth are a green color.
- D. The client has smooth knuckles.
Correct Answer: B
Rationale: Maintaining normal weight despite large meals and purging (suggested by restroom visits) is characteristic of bulimia. Jogging, green teeth, and smooth knuckles are less specific.
The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?
- A. Bowel sounds auscultated 15 times in one (1) minute.
- B. Belching after eating a heavy and fatty meal late at night.
- C. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.
- D. A decreased frequency of distress located in the epigastric region.
Correct Answer: C
Rationale: A 20 mm Hg drop in systolic BP on positional change suggests orthostatic hypotension, possibly from bleeding, requiring immediate intervention. Normal bowel sounds, belching, and reduced pain are less concerning.