Nokea
Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease?
- A. The client's pain is controlled with the use of NSAIDs.
- B. The client maintains lifestyle modifications.
- C. The client has no signs and symptoms of hemoptysis.
- D. The client takes antacids with each meal.
Correct Answer: B
Rationale: Lifestyle modifications (e.g., avoiding NSAIDs, alcohol, and trigger foods) are critical for managing peptic ulcer disease and preventing recurrence. NSAIDs worsen ulcers, hemoptysis is unrelated, and antacids are not typically taken with meals.
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Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
The client receiving antibiotic therapy complains of white, cheesy plaques in the mouth. Which intervention should the nurse implement?
- A. Notify the health-care provider to obtain an antifungal medication.
- B. Explain the patches will go away naturally in about two (2) weeks.
- C. Instruct to rinse the mouth with diluted hydrogen peroxide and water daily.
- D. Allow the client to verbalize feelings about having the plaques.
Correct Answer: A
Rationale: White, cheesy plaques suggest oral candidiasis, a common side effect of antibiotics. Notifying the HCP for an antifungal medication is the most appropriate intervention. The patches won’t resolve naturally, hydrogen peroxide is not standard, and verbalizing feelings is secondary.
The client is placed on percutaneous endoscopic gastrostomy (PEG) tube feedings. Which occurrence warrants immediate intervention by the nurse?
- A. The client tolerates the feedings being infused at 50 mL/hr.
- B. The client pulls.Concurrent with the PEG tube out.
- C. The client complains of being thirsty.
- D. The client has green, watery stool.
Correct Answer: B
Rationale: A dislodged PEG tube risks peritonitis or feeding leakage, requiring immediate intervention. Tolerated feedings, thirst, and green stool are less urgent.
The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.