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Which of the following information about a patient who has just been admitted to the hospital with nausea and vomiting requires the most rapid intervention by the nurse?
- A. The patient has taken only sips of water.
- B. The patient is lethargic and difficult to arouse.
- C. The patient's chart indicates a recent resection of the small intestine.
- D. The patient has been vomiting several times a day for the last 4 days.
Correct Answer: B
Rationale: A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information also is important to collect, but it does not require as quick action as the risk for aspiration.
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Which of the following presentations in a patient with a hiatal hernia who returned from a laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address immediately?
- A. The patient is experiencing intermittent waves of nausea
- B. The patient has absent breath sounds throughout the left lung.
- C. The patient has decreased bowel sounds in all four quadrants.
- D. The patient complains of 6/10 (0-10 scale) abdominal pain.
Correct Answer: B
Rationale: Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The abdominal pain and nausea also should be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.
A patient who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for management of severe rheumatoid arthritis has recently developed melena. Which of the following information should the nurse include in the teaching plan?
- A. Substitution of acetaminophen for the NSAID
- B. Use of enteric-coated NSAIDs to reduce gastric irritation
- C. Reasons for using corticosteroids to treat the rheumatoid arthritis
- D. The benefits of misoprostol in protecting the gastrointestinal (GI) mucosa
Correct Answer: D
Rationale: Misoprostol, a prostaglandin analogue, reduces acid secretion and incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.
The nurse is admitting a patient who is vomiting bright red blood to the emergency department. Which of the following assessments should the nurse perform first?
- A. Checking the level of consciousness
- B. Measuring the quantity of any emesis
- C. Auscultating the chest for breath sounds
- D. Taking the blood pressure (BP) and pulse
Correct Answer: D
Rationale: The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information also is important to obtain, but BP and pulse rate are the best indicators for hypoperfusion.
The nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer. Which of the following findings is of most concern?
- A. Bleeding during tooth brushing
- B. Painful blisters at the border of the lips
- C. Red, velvety patches on the buccal mucosa
- D. White, curdlike plaques on the posterior tongue
Correct Answer: C
Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (90%) of progression to malignant cancer. The other lesions are suggestive of acute processes (gingivitis, oral candidiasis, and herpes simplex).
The nurse is caring for a patient who has just arrived on the postoperative unit after having a laparoscopic esophagectomy for treatment of esophageal cancer. Which of the following nursing actions should be included in the postoperative plan of care?
- A. Elevate the head of the bed to at least 30 degrees.
- B. Reposition the nasogastric (NG) tube if drainage stops or decreases.
- C. Notify the doctor immediately about bloody NG drainage.
- D. Start oral fluids when the patient has active bowel sounds.
Correct Answer: A
Rationale: Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric secretions. The patient should be in the Fowler's or semi-Fowler's position. The NG tube should not be repositioned without consulting with the health care provider. Bloody NG drainage is expected for the first 8-12 hours. A swallowing study is needed before oral fluids are started.