Nokea
When a client has peptic ulcer disease, the nurse would expect a priority intervention to be:
- A. Assisting in inserting a Miller-Abbott tube
- B. Assisting in inserting an arterial pressure line
- C. Inserting a nasogastric tube
- D. Inserting an I.V.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?
- A. Supine
- B. Left side-lying
- C. Right side-lying
- D. Upright position.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?
- A. Inspect skin around the T tube daily for irritation.
- B. Irrigate the T tube every 4 hours to maintain patency.
- C. Maintain the client in a supine position while the T tube is in place.
- D. Keep the T tube clamped except during mealtimes.
Correct Answer: A
Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.
The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:
- A. Upper quadrant and radiates to the left scapula and shoulder
- B. Upper quadrant and radiates to the right scapula and shoulder
- C. Lower quadrant and radiates to the umbilicus
- D. Lower quadrant and radiates to the back
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?
- A. Lipase
- B. Lactase
- C. Amylase
- D. Trypsin
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client being seen in a physician's office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?
- A. Fast for 8 hours before the test.
- B. Eat a regular supper and breakfast.
- C. Continue to take all oral medications as scheduled.
- D. Monitor own bowel movement pattern for constipation
Correct Answer: A
Rationale: A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract.