Nokea
Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods?
- A. An antidiarrheal medication.
- B. An aminoglycoside antibiotic.
- C. An antitoxin medication.
- D. An ACE inhibitor medication.
Correct Answer: C
Rationale: Botulism is treated with antitoxin to neutralize the toxin and prevent further paralysis. Antidiarrheals, antibiotics, and ACE inhibitors are inappropriate for botulism.
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Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.
The charge nurse has just received the shift report. Which client should the nurse see first?
- A. The client diagnosed with Crohn's disease who had two (2) semiformed stools on the previous shift.
- B. The elderly client admitted from another facility who is complaining of constipation.
- C. The client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue turgor.
- D. The client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue.
Correct Answer: C
Rationale: The AIDS client with diarrhea and elastic turgor may still be dehydrated, requiring immediate assessment for electrolyte imbalances. Crohn’s stools, constipation, and hemorrhoid bleeding are less urgent.
The nurse is assessing the client recovering from abdominal surgery who has a patient-controlled analgesia (PCA) pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement?
- A. Insist the client take deep breaths.
- B. Notify the surgeon to request a chest x-ray.
- C. Determine the last time the client used the PCA pump.
- D. Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: C
Rationale: Determining PCA use assesses if overmedication is causing shallow respirations, guiding further action. Insisting on breathing, x-rays, or oxygen are secondary without cause.
The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?
- A. Reposition the client to promote T-tube drainage
- B. Telephone the surgeon to report these findings
- C. Ask a nursing assistant to obtain a blood pressure
- D. Record the findings and continue to monitor the client
Correct Answer: B
Rationale: A. Repositioning the client might promote bile flow into the T—tube if the client were lying on the tube. However, the jaundice indicates that the problem is internal. B. The T-tube is placed in the common bile duct to ensure patency of the duct. Lack of bile draining into the T—tube and jaundiced sclera are signs of an obstruction to the bile flow. This is most important to report to the surgeon. C. The client’s BP would not be affected by this situation. D. Recording the findings and continuing to monitor the client are inappropriate because the client is experiencing signs of a complication.