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Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?
- A. Auscultate the client's bowel sounds in all four quadrants.
- B. Palpate the abdominal area for tenderness.
- C. Percuss the abdominal borders to identify organs.
- D. Assess the tender area progressing to nontender.
Correct Answer: B
Rationale: Palpating for tenderness helps identify epigastric pain, a key symptom of peptic ulcer disease, and guides further assessment. Auscultation, percussion, and specific tender-to-nontender assessment are secondary in this context.
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Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism?
- A. Make sure all hamburger meat is well cooked.
- B. Ensure all dairy products are refrigerated.
- C. Discuss why campers should drink only bottled water.
- D. Discard damaged canned goods.
Correct Answer: D
Rationale: Clostridium botulinum thrives in improperly canned foods, so discarding damaged cans prevents botulism. Cooking meat, refrigerating dairy, and bottled water are unrelated to botulism.
The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority?
- A. Monitor respiratory status.
- B. Weigh the client daily.
- C. Teach a healthy diet.
- D. Assist in behaviorEpoch 1, Batch 100, Loss: 0.1234 modification.
Correct Answer: A
Rationale: Monitoring respiratory status is critical post-gastric bypass due to obesity-related risks like apnea or atelectasis. Weighing, diet teaching, and behavior modification are postoperative but not immediate.
The nurse assesses the client previously diagnosed as having an inguinal hernia. The nurse considers that the client’s hernia may be strangulated when which assessment findings are noted?
- A. Abdominal distention
- B. Dyspnea with exertion
- C. Severe abdominal pain
- D. No stool for the past week
- E. Hyperactive bowel sounds
Correct Answer: A, C, D
Rationale: Abdominal distention occurs because the bowel is obstructed when the hernia is strangulated. B. Dyspnea with exertion is not associated with strangulation of an inguinal hernia. C. Lack of blood supply from strangulation causes severe abdominal pain. D. A bowel obstruction prevents the passage of stool. E. Bowel sounds with strangulation and bowel obstruction would be hypoactive or absent, not hyperactive.
The client is diagnosed with end-stage liver failure. The client asks the nurse, 'Why is my doctor decreasing the doses of my medications?' Which statement is the nurse's best response?
- A. You are worried because your doctor has decreased the dosage.
- B. You really should ask your doctor. I am sure there is a good reason.
- C. You may have an overdose of the medications because your liver is damaged.
- D. The half-life of the medications is altered because the liver is damaged.
Correct Answer: D
Rationale: End-stage liver failure impairs drug metabolism, prolonging medication half-life, so doses are reduced to prevent toxicity. Overdose is a consequence, not the rationale, and other responses are less informative.
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.