Nokea
Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
- A. Absent bowel sounds
- B. Abdominal tenderness
- C. Left upper quadrant pain
- D. Palpable abdominal mass
Correct Answer: D
Rationale: The correct answer is a palpable abdominal mass. In a 46-year-old woman with acute pancreatitis, a palpable abdominal mass may indicate the presence of a pancreatic abscess, which requires rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common symptoms in acute pancreatitis but do not necessarily indicate an immediate need for surgical intervention. Therefore, the presence of a palpable abdominal mass is the most concerning finding in this scenario.
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The healthcare provider is managing a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be immediately reported to the healthcare provider?
- A. 3 episodes of vomiting in 1 hour.
- B. Periodic crying and irritability.
- C. Vigorous sucking on a pacifier.
- D. No measurable voiding in 4 hours.
Correct Answer: D
Rationale: The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening.
- B. Perform tests for sexually transmitted diseases.
- C. Discuss her high risk for cervical cancer.
- D. Refer the client to a family planning clinic.
Correct Answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV. Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes. Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?
- A. Feed the infant 30 cc of sterile water
- B. Position the infant on his back
- C. Administer antibiotics as ordered
- D. Allow the infant to breastfeed
Correct Answer: C
Rationale: Necrotizing enterocolitis (NEC) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician. Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered.
Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC. Choice B, positioning the infant on his back, is not directly related to the treatment of NEC. Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
- A. The patient's urine is bright yellow
- B. The patient's stools are tan colored
- C. The patient has increased pain after eating
- D. The patient complains of chronic heartburn
Correct Answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?
- A. Leukopenia.
- B. Hypokalemia.
- C. Polycythemia.
- D. Hypoglycemia.
Correct Answer: B
Rationale: When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.