Nokea
Which assessment data supports the client's diagnosis of gastric ulcer to the nurse?
- A. Presence of blood in the client's stool for the past month.
- B. Reports of a burning sensation moving like a wave.
- C. Sharp pain in the upper abdomen after eating a heavy meal.
- D. Complaints of epigastric pain 30 to 60 minutes after ingesting food.
Correct Answer: D
Rationale: Gastric ulcers typically cause epigastric pain 30–60 minutes after eating due to acid irritation of the ulcerated mucosa. Blood in stool is more indicative of lower GI issues, a wave-like sensation is vague, and sharp pain after heavy meals is less specific.
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The client is diagnosed with ulcerative colitis. Which sign/symptom warrants immediate intervention by the nurse?
- A. The client has 20 bloody stools a day.
- B. The client's oral temperature is 99.8°F.
- C. The client's abdomen is hard and rigid.
- D. The client complains of urinating when coughing.
Correct Answer: C
Rationale: A hard, rigid abdomen suggests peritonitis or perforation, a life-threatening complication of ulcerative colitis requiring immediate intervention. Frequent bloody stools are expected, low-grade fever is less urgent, and urinary incontinence is unrelated.
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client’s ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
- A. Pulse rate for the last 24 hours
- B. Urine output for the last 24 hours
- C. Weight over the last 3 days
- D. Ability to move the lower extremities
- E. Temperature readings for the last 24 hours
Correct Answer: A, B, C, E
Rationale: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.
The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.