Nokea
Which statement made by the client indicates to the nurse the client may be experiencing GERD?
- A. My chest hurts when I walk up the stairs in my home.
- B. I take antacid tablets with me wherever I go.
- C. My spouse tells me I snore very loudly at night.
- D. I drink six (6) to seven (7) soft drinks every day.
Correct Answer: B
Rationale: Frequent use of antacids suggests ongoing heartburn or reflux symptoms, a hallmark of GERD. Chest pain with exertion is more suggestive of cardiac issues, snoring may indicate sleep apnea, and soft drink consumption is a risk factor but not a direct symptom.
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The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse?
- A. Absent bowel sounds in all four (4) quadrants.
- B. The T-tube has 60 mL of green drainage.
- C. Urine output of 100 mL in the past three (3) hours.
- D. Refusal to turn, deep breathe, and cough.
Correct Answer: D
Rationale: Refusal to turn, deep breathe, and cough increases the risk of atelectasis and pneumonia post-surgery, requiring immediate intervention. Absent bowel sounds, T-tube drainage, and urine output are expected at this stage.
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.
The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?
- A. The 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numerical scale
- B. The 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes
- C. The 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night
- D. The 54-year-old client with cirrhosis and jaundice who is reporting having itching all over the body
Correct Answer: B
Rationale: A. The client with a pain rating of 6 out of 10 on a numerical scale needs attention, but the pain is not a life-threatening concern. B. Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The nurse should assess this client first. C. The client who is postcholecystectomy is reported as being stable and could be assessed last. D. The client reporting itching needs attention, but the itching is not a life-threatening concern.
Warm oatmeal (Aveeno) baths are ordered for a client with cancer of the pancreas. What is the chief purpose of this procedure for this client?
- A. Relief of paralytic ileus
- B. Alleviation of pruritus associated with jaundice
- C. Relief of bloating and fullness after eating
- D. Reducing the fever associated with the disease
Correct Answer: B
Rationale: Oatmeal baths alleviate pruritus caused by jaundice, a common symptom in pancreatic cancer due to bile salt accumulation.
Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?
- A. Liver function tests.
- B. Kidney function tests.
- C. Cardiac function tests.
- D. Bone density scan.
Correct Answer: C
Rationale: Cardiac function tests (e.g., ECG) monitor for arrhythmias or heart failure, common in severe anorexia due to electrolyte imbalances and starvation. Liver, kidney, and bone tests are less urgent.