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Which data should the nurse expect to assess in the client diagnosed with acute gastroenteritis?
- A. Decreased gurgling sounds on auscultation of the abdominal wall.
- B. A hard, firm, edematous abdomen on palpation.
- C. Frequent, small melena-type liquid bowel movements.
- D. Bowel assessment reveals loud, rushing bowel sounds.
Correct Answer: D
Rationale: Loud, rushing bowel sounds are expected in gastroenteritis due to increased peristalsis from irritation. Decreased sounds, hard abdomen, or melena suggest other conditions.
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A nasogastric tube is ordered for an alert adult client. In addition to the tube and basin, what is essential for the nurse to have at the bedside during the procedure?
- A. A 5-cc syringe filled with water
- B. A glass filled with water and a straw
- C. A large clamp
- D. A container of sterile water
Correct Answer: B
Rationale: A glass of water with a straw helps the client swallow during nasogastric tube insertion, facilitating passage.
Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication?
- A. The client's pulse is 65 beats per minute.
- B. The client has shallow respirations.
- C. The client's bowel sounds are 20 per minute.
- D. The client uses a pillow to splint when coughing.
Correct Answer: B
Rationale: Shallow respirations suggest pain, as patients avoid deep breathing to minimize discomfort. Normal pulse, bowel sounds, and splinting are less direct indicators of pain.
Which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications?
- A. Alteration in bowel elimination patterns.
- B. Knowledge deficit in the causes of ulcers.
- C. Inability to cope with changing family roles.
- D. Potential for alteration in gastric emptying.
Correct Answer: A
Rationale: Peptic ulcer disease can lead to complications like bleeding or perforation, which alter bowel elimination patterns (e.g., melena or hematochezia). Knowledge deficits and coping issues are psychosocial, and gastric emptying is less commonly affected.
Following an esophagectomy with colon interposition (esophagoenterostomy) for esophageal cancer, the client is beginning to eat oral foods. The nurse monitors for aspiration because the client no longer has which structure?
- A. A stomach
- B. A pyloric sphincter
- C. A pharynx
- D. A lower esophageal sphincter
Correct Answer: D
Rationale: A. All or part of the stomach will remain intact following an esophagoenterostomy. B. The pyloric sphincter will remain intact following an esophagoenterostomy. C. The pharynx will remain intact following an esophagoenterostomy. D. An esophagectomy for cancer involves removal of the lower esophageal sphincter, which normally functions to keep food from refluxing back into the esophagus. The absence of the lower esophageal sphincter places the client at risk for aspiration.
Which information should the nurse teach the client post-barium enema procedure?
- A. The client should not eat or drink anything for four (4) hours.
- B. The client should remain on bedrest until the sedative wears off.
- C. The client should take a mild laxative to help expel the barium.
- D. The client will have normal elimination color and pattern.
Correct Answer: C
Rationale: A mild laxative helps expel barium, preventing constipation or impaction post-barium enema. NPO, bedrest, and normal stool color are incorrect.