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While caring for a patient who is suspected of having appendicitis, the nurse overhears his conversation with a loved one. Which of the following statements would prompt immediate intervention?
- A. The pain doesn't feel as bad now. I think it was just a stomach ache.
- B. Would you mind getting me an ice pack?
- C. I know I'm not supposed to eat anything right now, but I'm hungry.
- D. I wonder if I can play in the basketball game on Monday.
Correct Answer: A
Rationale: Sudden pain relief (A) in suspected appendicitis may indicate appendix rupture, requiring immediate intervention to prevent complications like peritonitis.
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The nurse cares for a client who reports dumping syndrome following gastric bypass surgery. To alleviate the symptoms of dumping syndrome, the nurse should recommend that the client. Select all that apply.
- A. Take a dose of their prescribed proton pump inhibitor immediately before meals.
- B. Stay upright for 30 minutes following eating.
- C. Eat high-fiber foods to decrease late dumping syndrome.
- D. Increase their intake of simple carbohydrates to prevent spikes in blood sugar.
- E. Eat five to six small meals a day to avoid overloading the stomach.
Correct Answer: B,C,E
Rationale: Staying upright (B), eating high-fiber foods (C), and consuming small, frequent meals (E) slow gastric emptying, reducing dumping syndrome symptoms. PPIs (A) are unrelated, and simple carbohydrates (D) worsen symptoms.
The nurse is supervising a student nurse performing an abdominal assessment on a client with gastroenteritis. It would indicate effective technique if the student performs the assessment in which order?
- A. Auscultation, inspection, palpation, percussion
- B. Inspection, palpation, percussion, auscultation
- C. Palpation, percussion, inspection, auscultation
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation (D). Auscultation before palpation prevents altering bowel sounds.
The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. This action is appropriate and does not require follow-up. The nurse understands that the primary purpose of placing this tube is to
- A. Feed the client.
- B. Decompress the stomach.
- C. Irrigate the stomach.
- D. Administer medications.
Correct Answer: B
Rationale: A nasogastric tube in paralytic ileus (B) decompresses the stomach, relieving distention and preventing complications like aspiration.
The nurse is caring for a client with diverticulosis who reports difficulty getting enough dietary fiber. The nurse should anticipate the primary healthcare provider (PHCP) will prescribe
- A. Psyllium
- B. Oil-retention enema
- C. Codeine
- D. Bisacodyl
Correct Answer: A
Rationale: Psyllium, a bulk-forming laxative, increases fiber intake, promoting regular bowel movements in diverticulosis. Enemas, codeine (which slows motility), and bisacodyl (a stimulant laxative) are not appropriate for increasing dietary fiber.
The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply.
- A. Draw up 30 mL of warm water into the syringe.
- B. Unclamp the suction tubing near the connection site to instill water.
- C. Place the tip of the syringe in the tube to gently instill warm water.
- D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
- E. After instilling the water, hold the end of the NG tube over an irrigation tray.
- F. Observe for return of NG drainage into an available container.
Correct Answer: A,C,F
Rationale: Using 30 mL of warm water (A), gently instilling it into the tube (C), and observing for drainage return (F) ensure proper NGT irrigation without complications. Unclamping suction (B) or using the air vent (D) is incorrect, and holding the tube over a tray (E) is unnecessary.