The nurse is caring for a client with appendicitis experiencing pain. Which pain relief method would be inappropriate for this client?
Rationale:
Using a heating pad on the abdomen is inappropriate for a client with appendicitis experiencing pain. Heat can increase inflammation and worsen the condition, potentially leading to complications.
A: Applying ice packs to the abdomen can help reduce inflammation and numb the area, providing relief for acute abdominal pain associated with appendicitis.
B: Practicing breathing exercises with the patient can promote relaxation and help manage pain through distraction techniques, making it a beneficial approach in this situation.
D: Encouraging rest allows the body to heal and reduces movement-related discomfort, making it a supportive method for managing appendicitis pain.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) cares for a 21-year-old male client
Item 1 of 1
Nurses' Notes
1650: Client reports severe abdominal pain that radiates to his left shoulder. The client was tossing around the football with friends, and after being tackled, he began experiencing intense pain that worsened. He denies any medical history but is currently being treated for infectious mononucleosis and 'needed to get some fresh air,' so he started playing football with friends. During the assessment, the client was alert and fully oriented. He reports his abdominal pain is in the left upper quadrant, which radiates to his shoulder, as an 8/10 on the Numerical Rating Scale. Slight bruising was noted on the client's abdomen. A blotchy rash was observed on his back. His abdomen was slightly distended, taut, and tender to touch. Lung sounds are clear bilaterally. Peripheral pulses 2+. Skin is hot to the touch. Cervical lymphadenopathy is present. Vital signs: T 100.4°F (38°C), P 110, RR 21, BP 115/76.
Which of the following assessment findings require immediate follow-up? Select all that apply.
Rationale:
Reports of abdominal pain, elevated pulse, and concerning abdominal assessment findings necessitate immediate follow-up. These symptoms suggest potential severe underlying issues, especially given the client's recent activities and current infection, requiring prompt intervention to prevent complications.
B: Temperature A mild fever, while noteworthy, typically does not require urgent intervention alone unless accompanied by other severe symptoms or significant changes in the patient's condition.
D: Rash Although a blotchy rash is present, it does not inherently indicate a life-threatening issue that demands immediate attention compared to abdominal pain and vital signs.
E: Cervical lymphadenopathy While lymphadenopathy can indicate infection, it is not an acute finding necessitating immediate follow-up compared to the client's abdominal and vital sign concerns.
The nurse is caring for a client with a hiatal hernia who is being discharged today. The nurse talks to them regarding methods to manage symptoms and promote overall well-being associated with their condition. Which of the following statements from the client indicate that teaching is successful?
Rationale:
I need to wear loose-fitting clothes. Wearing loose-fitting clothing helps reduce pressure on the abdomen, which can alleviate symptoms of a hiatal hernia and improve overall comfort and well-being.
B: After a meal, I must lie down to avoid dumping syndrome. Lying down after meals can exacerbate symptoms in hiatal hernia patients rather than preventing complications.
C: I need to eat three large meals a day. Consuming three large meals increases abdominal pressure, which can worsen symptoms; smaller, more frequent meals are recommended instead.
D: I can go to my favorite Indian restaurant anytime of the week. While dining out is fine, certain foods common in Indian cuisine may trigger symptoms, necessitating caution and dietary awareness.
The nurse is reviewing gastrointestinal assessment with a group of student nurses. It would be correct if the student identifies which of the following would cause hyperactive bowel sounds?
Rationale:
Hyperactive bowel sounds can be caused by gastroenteritis. This condition stimulates the gastrointestinal tract due to inflammation and infection, leading to increased peristalsis and resultant heightened bowel sounds during assessment.
A: Paralytic ileus This condition results in a decrease in bowel activity, leading to diminished or absent bowel sounds rather than hyperactivity.
C: Late bowel obstruction As the condition progresses, bowel sounds typically decrease, reflecting reduced motility rather than an increase.
D: Peritonitis Inflammation of the peritoneum often leads to diminished bowel sounds due to decreased gastrointestinal motility, not hyperactivity.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 3 of 6
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
The client is at risk for developing........... and .......
Rationale:
The client is at risk for developing gastrointestinal bleeding and hypovolemia.
Gastrointestinal bleeding is a potential complication of acute pancreatitis due to inflammation and erosion of blood vessels in the pancreas. Additionally, hypovolemia may occur from vomiting and fluid shifts, leading to compromised circulation and potential shock, which is critical given the client’s ongoing symptoms and history of chronic alcohol use.
A: Cholelithiasis This condition involves the formation of gallstones, which is not indicated here as imaging shows no gallstones and the gallbladder is distended without wall thickening.
B: Pulmonary edema The client's respiratory status, with slightly diminished breath sounds and normal oxygen saturation, does not signal pulmonary edema, which would typically present with more severe respiratory distress and abnormal lung findings.
D: Intestinal obstruction No evidence of bowel obstruction or wall thickening is noted in imaging results. The client's abdominal assessment does not support obstruction, as bowel sounds are diminished but not absent.
E: Diabetic ketoacidosis (DKA) While the client has elevated glucose levels, the absence of metabolic acidosis or ketones in the context suggests that DKA is not a likely risk in this acute pancreatitis case.
G: Pulmonary embolism There are no signs of deep vein thrombosis or respiratory distress that would typically accompany a pulmonary embolism, making this an unlikely risk for the client.
The nurse is caring for a client with suspected bowel perforation. Which of the following would be contraindicated?
Rationale:
Administering milk of magnesia following an upper GI study. Administering this laxative could exacerbate bowel perforation by increasing intestinal pressure and worsening the client's condition, posing significant risks to their health.
A: Administering gastrografin for an upper GI x-ray. This contrast agent is safe for imaging and can help diagnose gastrointestinal issues without exacerbating a perforation.
B: An exploratory laparotomy procedure. This surgical intervention is appropriate for diagnosing and treating bowel perforation and would not be contraindicated in this scenario.
D: An abdominal CT scan. This imaging technique is vital for confirming bowel perforation and guiding further management, making it a necessary diagnostic tool in this context.
A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting?
Rationale:
Intermittent suction at 70 mmHg is the appropriate setting for gastric decompression in clients with bowel obstruction. This method minimizes gastric irritation while effectively relieving pressure and allows for better mucosal healing.
B: Intermittent suction at 100 mmHg exerts excessive negative pressure, potentially leading to mucosal damage and discomfort, which is not ideal for managing bowel obstruction.
C: Continuous suction at 100 mmHg maintains constant pressure that may cause irritation and injury to the gastric lining, making it unsuitable for safe gastric decompression in this scenario.
D: Continuous suction at 70 mmHg, while lower than 100 mmHg, still poses a risk of irritation due to its continuous nature, which can compromise mucosal integrity during treatment.
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.
Rationale:
Staying upright for 30 minutes following eating, consuming high-fiber foods, and eating five to six small meals a day can help mitigate the symptoms of dumping syndrome by promoting proper digestion and nutrient absorption.
A: Take a dose of their prescribed proton pump inhibitor immediately before meals. This action does not address the rapid gastric emptying characteristic of dumping syndrome and may not alleviate symptoms effectively.
D: Increase their intake of simple carbohydrates to prevent spikes in blood sugar. Simple carbohydrates can exacerbate symptoms by causing rapid glucose absorption, leading to increased risk of hypoglycemia after meals.
The nurse is caring for a client with a paralytic ileus following an appendectomy. Which intervention would be appropriate for the nurse to take?
Rationale:
B: Prepare for the insertion of a nasogastric tube. In cases of paralytic ileus, the gastrointestinal tract is not functioning properly, and a nasogastric tube can help relieve pressure and facilitate decompression.
A: Assess the client for hyperkalemia. While electrolyte imbalances can occur post-surgery, hyperkalemia is not directly related to paralytic ileus and would not be the immediate concern.
C: Assess the surgical wound for approximation. Although monitoring the surgical site is necessary, it does not address the primary issue of the gastrointestinal obstruction caused by paralytic ileus.
D: Instruct the client to chew their food more slowly. Chewing food slowly does not address the underlying problem of intestinal paralysis and would not aid in resolving the ileus condition.
The nurse has just finished assisting the physician in performing a paracentesis. What should be the priority nursing intervention following the procedure?
Rationale:
Monitor for signs of hypovolemia. Following a paracentesis, rapid fluid removal can lead to decreased intravascular volume, making it vital to observe the patient for symptoms of hypovolemia.
A: Administer analgesics to control pain. While pain management is important, it is secondary to monitoring the patient’s hemodynamic status after fluid removal, which is critical for patient safety.
B: Monitor for signs of infection. Although infection is a concern post-procedure, the immediate priority involves assessing for hypovolemia, as it can lead to more acute complications if not addressed.
D: Ensure that the ascitic fluid is sent to the lab for analysis. Sending the fluid for analysis is necessary but does not take precedence over monitoring the patient’s vital signs and fluid status following the procedure.
The nurse prepares a client for a computed tomography (CT) scan of their abdomen and pelvis with intravenous (IV) contrast. The nurse should take which action before the client's exam?
Rationale:
Clients receiving CT scans with IV contrast often experience a flushing sensation due to the iodine-based contrast material. This sensation can be unsettling, so informing clients prepares them for the experience and alleviates anxiety.
A: Remove any medicated patches before the exam. While it's important to ensure safety, this action is not specifically required prior to a CT scan with contrast.
B: Instruct the client to empty their bladder right before the test. Although bladder preparation may be recommended in some imaging studies, it is not a standard requirement for abdominal and pelvic CT scans.
D: Assess the client for an implantable pacemaker. While assessing for a pacemaker is vital in certain imaging procedures, it is not specifically necessary for a standard CT scan with IV contrast.
The following scenario applies to the next 1 items
The nurse is caring for a client immediately following an abdominal paracentesis
Item 1 of 1
Procedure Note
1845 - Emergency ultrasound-guided abdominal paracentesis was performed because the client presented with labored respirations, dyspnea, abdominal cramping, and overall discomfort. Informed consent was obtained, and the client agreed to the procedure. Prior to the procedure, the client emptied their bladder. The site was cleaned and numbed with 1% lidocaine, and using an aseptic technique and an ultrasound; a 14-gauge catheter was inserted to remove 10 mL of clear ascitic fluid. Subsequently, the fluid was drained via tubing. 6 liters of fluid were removed. The client tolerated the procedure well and reported immediate relief in the dyspnea and abdominal cramping following the procedure.
Immediately following this procedure, the nurse should monitor the client's ............. because the client has the risk of ........... If the client should experience this immediate post-procedure complication, the nurse should anticipate a prescription for ........
Rationale:
The nurse should monitor the client's blood pressure because the client has the risk of hypotension. If the client should experience this immediate post-procedure complication, the nurse should anticipate a prescription for albumin.
B: Urinary output Monitoring urinary output is not a priority immediately after this procedure, as the primary concern is assessing blood pressure and the potential for hypotension.
D: Peritonitis Although peritonitis is a possible complication, the scenario does not indicate any immediate signs or symptoms that would warrant this as a primary concern post-procedure.
F: Ceftriaxone Ceftriaxone may be used for infections; however, it is not immediately relevant for the complications anticipated after an abdominal paracentesis, such as hypotension.
Which of the following most impacts a client's food preferences?
Rationale:
Culture and cultural background significantly impact a client's food preferences by shaping their taste, beliefs, and traditions surrounding food. These factors dictate what is considered acceptable or desirable to eat, influencing choices consistently.
B: The frequency of grocery shopping influences meal planning and food selection but does not fundamentally shape a person’s inherent preferences for specific foods or cuisines.
C: The availability of foods locally affects what is accessible but does not determine an individual’s intrinsic likes or dislikes influenced by their cultural upbringing.
D: The costs associated with food can influence purchasing decisions but do not dictate the underlying preferences shaped by cultural influences and personal experiences with food.
The nurse is assessing a client with cholecystitis. To support this finding, the nurse expects the client to localize the pain in the
Rationale:
The pain is localized in the right upper quadrant, radiating to the right shoulder. This pain pattern is typical in cholecystitis due to irritation of the diaphragm and associated nerve pathways.
B: Right upper quadrant, radiating to the left shoulder. This radiating pattern does not align with cholecystitis, as left shoulder pain typically indicates issues related to the heart or spleen.
C: Right lower quadrant, radiating to the pelvic bones. Cholecystitis primarily affects the upper abdomen, and pain in the lower quadrant suggests other gastrointestinal conditions, like appendicitis.
D: Right lower quadrant, radiating to the umbilicus. Pain in the right lower quadrant is not characteristic of cholecystitis and is more indicative of conditions like diverticulitis or appendicitis.
The nurse has educated a client scheduled to have an endoscopic retrograde cholangiopancreatography (ERCP). Which of the following client statements would indicate the need for additional teaching by the nurse? Select all that apply.
Rationale:
I will have to do a bowel prep before this procedure. This statement indicates a need for additional teaching, as bowel preparation is typically not required prior to an ERCP.
B: I will have to do a bowel prep before this procedure. ERCP generally does not necessitate bowel preparation, making this statement misleading regarding the procedure's requirements.
D: I should notify my physician if I have abdominal pain and distention for one or two days following this procedure. This is vague; the client should report any severe or persistent symptoms immediately.
E: I can expect to have white stools one to two days following this procedure. White stools are concerning and could indicate complications, thus not a normal expectation post-ERCP.
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.
Rationale:
A: Draw up 30 mL of warm water into the syringe.
Irrigating an NGT requires using warm water to ensure comfort and effectiveness. Drawing up 30 mL allows for sufficient fluid to clear the tube and maintain patency, which is essential for proper function.
B: Unclamp the suction tubing near the connection site to instill water.
Unclamping the suction tubing disrupts the suction function, potentially leading to inadequate drainage and increased risk of complications during the irrigation process.
D: Place the syringe in the blue air vent of a Salem sump or double-lumen tube.
Using the air vent for irrigation can cause improper technique, preventing effective fluid instillation and leading to complications such as air trapping or ineffective irrigation.
E: After instilling the water, hold the end of the NG tube over an irrigation tray.
Holding the NG tube over an irrigation tray is unnecessary and does not contribute to the irrigation process. Proper handling and disposal methods should be prioritized instead.
F: Observe for return of NG drainage into an available container.
Monitoring for drainage return verifies the effectiveness of the irrigation procedure, ensuring the tube is functioning properly and confirming that the water has cleared the tube.
Which of the following interventions is helpful in reducing the effects of Gastroesophageal Reflux Disease (GERD)?
Rationale:
Elevating the head of the bed on 4-6 inch blocks is helpful in reducing the effects of Gastroesophageal Reflux Disease (GERD).
Raising the head of the bed helps prevent stomach acid from flowing back into the esophagus during sleep, thus minimizing nighttime symptoms and promoting better digestion. This positional change can significantly alleviate discomfort associated with GERD, leading to improved sleep quality.
A: Lie down after eating. This position can exacerbate GERD symptoms by allowing stomach acid to easily flow back into the esophagus, increasing discomfort and heartburn.
B: Wear a girdle. Tight clothing, like a girdle, can put additional pressure on the abdomen, potentially worsening reflux symptoms instead of alleviating them.
D: Increase fluid intake just before bedtime. Drinking fluids before bed can lead to increased pressure in the stomach, which may trigger reflux symptoms and disrupt sleep quality.
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
Rationale:
The primary purpose of placing a nasogastric tube is to decompress the stomach. This action alleviates pressure, reduces distention, and allows for the removal of gastric contents, which is crucial for a client with paralytic ileus.
A: Feed the client. While feeding can be a function of a nasogastric tube, it is not the primary purpose when dealing with paralytic ileus.
C: Irrigate the stomach. Irrigation may occur, but it is not the main goal of tube insertion in this specific clinical scenario, which focuses on decompression.
D: Administer medications. Although medications can be delivered via a nasogastric tube, the primary intent in this context is to relieve gastric pressure rather than to provide medication.
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit cares for a client who is postoperative
Item 1 of 1
Progress Notes
Day 2
Status-post open (partial) gastrectomy. Client reports abdominal pain 6/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is taut with hypoactive bowel sounds in all quadrants. Reports passing no flatus. Endorses occasional nausea with no vomiting. Incision approximated with moderate serosanguinous drainage. Abnormal laboratory data noted: BUN 19 mg/dL (10 – 20 mg/dL); Creatinine 1.0 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.3 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, only consuming 10-15% of meals. No VS abnormalities.
Day 3
Status-post open (partial) gastrectomy. Client reports abdominal pain 4/10 on the Numerical Rating Scale. Client is still receiving patient-controlled analgesia (PCA) of fentanyl. Abdomen is distended, with hypoactive bowel sounds in all quadrants. Reports passing no flatus and is hiccuping during the exam. Endorses persistent nausea and occasional vomiting with no relief from prescribed ondansetron. Incision approximated with scant serosanguinous drainage. Abnormal laboratory data noted: BUN 23 mg/dL (10 – 20 mg/dL); Creatinine 1.3 mg/dL (0.6 – 1.2 mg/dL); Potassium 3.1 mEq/l (3.5 – 5.0 mEq/l). Not tolerating a clear liquid diet, nursing reports 0% consumption of meals. VS showed an oral temperature of 99.5°F (37.5°C).
The client is at highest risk for [condition] as evidenced by the client's............and............
Rationale:
The client is at highest risk for paralytic ileus as evidenced by the client's distended abdomen and reports of passing no flatus.
The presence of a distended abdomen, hypoactive bowel sounds, and the inability to pass flatus strongly indicate a functional obstruction, known as paralytic ileus, especially following surgery. The combination of these symptoms highlights the client's compromised gastrointestinal motility.
B: Inadequate pain control does not directly correlate with the signs of gastrointestinal dysfunction observed, such as abdominal distention and lack of flatus, which are more indicative of paralytic ileus.
D: Infusion of fentanyl may contribute to sedation, but the critical indicators of paralytic ileus primarily stem from the client’s abdominal symptoms and not solely from pain management strategies.
E: Hypokalemia, while present, does not alone explain the client's abdominal distension and inability to pass flatus, which are more specific indicators of paralytic ileus rather than electrolyte imbalance.
F: Wound assessment is not directly linked to the current gastrointestinal symptoms, and the abdominal issues presented are more relevant to the risk of paralytic ileus rather than wound status.
G: Infusion of fentanyl does not directly lead to the gastrointestinal signs exhibited, as the risk of paralytic ileus is primarily associated with the postoperative state and the observed abdominal symptoms.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as risk factors for developing colorectal cancer? Select all that apply.
Rationale:
Ulcerative colitis, a low-fiber diet, excessive alcohol consumption, and African-American ethnicity are recognized risk factors for developing colorectal cancer due to their established links to inflammation and cancer development over time.
B: Body Mass Index (BMI) of 21 reflects a healthy weight range, not associated with heightened colorectal cancer risk. Normal BMI does not indicate any predisposition to cancer.
C: Human Immunodeficiency Virus (HIV) infection does not have a direct correlation with colorectal cancer risk. HIV primarily affects immune function rather than directly contributing to colorectal malignancies.
The nurse in the intensive care unit is caring for a client being treated for necrotizing pancreatitis. Which of the following findings would indicate the client is experiencing a complication?
Rationale:
Decreased lung sounds in the left lower lung fields indicate the client may be experiencing a respiratory complication, possibly due to fluid accumulation or infection associated with necrotizing pancreatitis.
A: Periumbilical bruising This finding, known as Cullen's sign, can indicate hemorrhage but is not a direct complication of necrotizing pancreatitis itself.
B: Abdominal pain rated 5/10 on the numerical rating scale While abdominal pain is common in pancreatitis, a rating of 5/10 does not signify a complication.
C: White blood cell count 13,500 mm3 [5,000-10,000 mm3] An elevated white blood cell count suggests infection or inflammation but does not specifically indicate a complication in this context.
The nurse is caring for a client with anemia and occult blood in the stool. Which of the following medications should the nurse question?
Rationale:
Enoxaparin should be questioned. This anticoagulant can increase the risk of bleeding in a client with anemia and occult blood in the stool, potentially exacerbating the client’s condition and leading to serious complications.
A: Iron sucrose This medication is essential for addressing iron deficiency in anemia, supporting the client's recovery by replenishing iron stores and improving hemoglobin levels effectively.
C: Sucralfate This drug acts as a mucosal protectant, creating a barrier against stomach acids, thus not interfering with the management of anemia or the presence of occult blood.
D: Hydroxyurea Hydroxyurea is primarily used in certain blood disorders and does not have a direct impact on anemia management or pose a bleeding risk like anticoagulants do.
The nurse is caring for a client diagnosed with peptic ulcer disease. The nurse anticipates a prescription for which medication?
Rationale:
Famotidine
Famotidine is a histamine-2 receptor antagonist that reduces stomach acid production, making it an effective treatment for peptic ulcer disease. This medication helps alleviate ulcer symptoms and promotes healing of the gastrointestinal lining, aligning with the typical therapeutic approach for managing such conditions.
A: Ondansetron Antiemetic medication used primarily for nausea and vomiting, not for treating peptic ulcers or reducing gastric acid secretions.
B: Diphenoxylate with atropine Primarily prescribed for diarrhea management, this combination does not address the underlying gastric acid issues associated with peptic ulcers.
D: Psyllium A fiber supplement that aids in constipation relief, lacking any therapeutic effect on gastric acid production or peptic ulcer management.
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
Rationale:
Psyllium. This fiber supplement is often recommended for clients with diverticulosis to improve bowel regularity and ease symptoms by increasing dietary fiber intake, which helps prevent complications associated with the condition.
B: Oil-retention enema. This approach primarily addresses constipation through lubrication rather than increasing dietary fiber intake, which is the main concern for the client’s diverticulosis management.
C: Codeine. This opioid medication may alleviate pain but potentially leads to constipation, thus countering the goal of increasing fiber intake and optimizing bowel health in diverticulosis.
D: Bisacodyl. This stimulant laxative promotes bowel movements but does not enhance dietary fiber, making it unsuitable for addressing the client's need for improved fiber consumption in diverticulosis.
The nurse is caring for a client who is receiving prescribed dicyclomine. Which of the following client findings would indicate a therapeutic response?
Rationale:
Decreased abdominal cramping. This finding shows a therapeutic response to dicyclomine, which is an anticholinergic medication used to alleviate gastrointestinal symptoms, particularly by relaxing the muscles in the digestive tract.
B: Absence of nausea and vomiting. While this is a positive outcome, it does not specifically indicate therapeutic effectiveness of dicyclomine, which primarily targets abdominal cramping.
C: Decreased urinary retention. This symptom does not relate to dicyclomine's intended use, as the medication focuses on gastrointestinal relief rather than affecting urinary function in patients.
D: Less burning with urination. This finding pertains to urinary symptoms, which are unrelated to the primary action of dicyclomine, highlighting a lack of correlation with therapeutic effects for abdominal discomfort.
The nurse is caring for a client who reports excessive flatulence and abdominal cramping. The nurse anticipates a prescription for which of the following?
Rationale:
Simethicone is the anticipated prescription for the client experiencing excessive flatulence and abdominal cramping. This medication effectively reduces gas buildup and alleviates discomfort by breaking up gas bubbles in the gastrointestinal tract.
B: Omeprazole does not address gas-related symptoms, as it primarily functions to reduce stomach acid and treat conditions like GERD, not flatulence or cramping.
C: Ferrous sulfate is an iron supplement used to treat anemia, having no relevance to the management of gas or abdominal discomfort, thus being unsuitable for this situation.
D: Cimetidine is an H2 blocker intended for reducing stomach acid; it does not target gas or cramping, resulting in ineffectiveness for the client's reported symptoms.
The nurse is caring for a client in the intensive care unit (ICU) being mechanically ventilated via an endotracheal tube (ETT) for head trauma following a motor vehicle crash (MVC). The primary healthcare provider (PHCP) prescribes famotidine 20 mg intravenous (IV) push. The nurse understands that this medication is intended to
Rationale:
Famotidine 20 mg IV push is intended to prevent the formation of stress ulcers. This medication reduces gastric acid secretion, which is particularly beneficial for clients under severe stress, such as those in the ICU.
A: Decrease any gagging by the ETT. Famotidine does not address gag reflexes or airway management issues associated with endotracheal tubes, focusing instead on gastric acid reduction.
C: Provide sedation. Famotidine does not possess sedative properties; it primarily acts as an H2 receptor antagonist to diminish gastric acid production rather than influencing sedation levels.
D: Increase gastric motility. Famotidine's action is centered on reducing acid secretion, not enhancing gastric motility, which involves different pharmacological mechanisms unrelated to its primary function.
The nurse is caring for a client receiving total parenteral nutrition (TPN), which was initiated twelve hours ago. The priority assessment for this client is which of the following?
Rationale:
D: Capillary blood glucose. Monitoring capillary blood glucose is crucial for clients receiving TPN, as the high glucose content can lead to hyperglycemia, necessitating regular assessment to prevent complications and ensure safe management.
A: Urine output. While urine output is important for overall fluid balance, it is not the immediate priority in the context of TPN initiation and glucose management.
B: Oral temperature. Oral temperature assessment does not directly correlate with the immediate metabolic changes associated with TPN and its potential effects on blood glucose levels.
C: Weight. Weight measurement is valuable for monitoring nutrition status over time but does not provide immediate feedback on the metabolic effects of TPN that require urgent assessment.
The nurse is assessing a client who has appendicitis. Which of the following would be an expected finding? Select all that apply.
Rationale:
Leukocytosis, fever, nausea and vomiting, and anorexia are expected findings in a client with appendicitis. These symptoms indicate an inflammatory response, aligning with the body's reaction to infection and irritation of the appendix.
B: Melena This symptom relates to gastrointestinal bleeding, typically associated with conditions affecting the upper GI tract, not with appendicitis, which primarily presents with abdominal pain and inflammation.
A nurse is caring for a client diagnosed with a duodenal ulcer. Which medication facilitates healing by forming a protective lining over the client's ulcer?
Rationale:
Sucralfate facilitates healing by forming a protective barrier over the ulcer, promoting tissue repair and preventing further irritation from gastric acids. This unique action specifically targets the ulcer site, enhancing recovery.
A: Famotidine This medication reduces stomach acid production but does not create a protective lining over the ulcer, making it less effective for direct healing.
B: Omeprazole As a proton pump inhibitor, it lowers acid secretion but lacks the specific mechanism to form a protective coating on the ulcer itself.
D: Cimetidine Similar to famotidine, it decreases acid production but does not provide the protective barrier necessary for ulcer healing, limiting its therapeutic effect on the ulcer.
A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?
Rationale:
D: Presence of a wet, gurgling cough after drinking water. This finding suggests potential aspiration risk, indicating that the client may have difficulty protecting their airway and requires immediate intervention to prevent complications such as pneumonia or choking.
A: Slight cough after sipping water. A slight cough may be a normal response and doesn’t necessarily indicate significant dysphagia or aspiration risk requiring urgent intervention at this stage.
B: Hoarseness of voice during speech. While hoarseness can indicate vocal cord strain, it does not directly suggest a compromise in swallowing safety or an immediate need for intervention.
C: Reports of mild throat discomfort when swallowing. Mild discomfort does not inherently signal a severe dysphagia issue that necessitates immediate intervention, as it can occur for various benign reasons.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 2 of 6
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
Orders
0600
• Cardiac monitoring
• NPO
• CBC
• CMP
• LFTs
• Amylase
• Lipase
• CT abdomen with contrast
The nurse is reviewing assessment findings to differentiate between acute pancreatitis and cholecystitis. For each assessment finding below, click to specify if the finding is consistent with the disease process of acute pancreatitis or cholecystitis. Each finding may support more than one (1) disease process. Each column must have at least one (1) response option selected.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Severe epigastric pain
B
Gray-blue discoloration of the flanks
C
Nausea and vomiting
D
Leukocytosis
E
Elevated lipase and amylase
F
Hypocalcemia
Rationale:
Severe epigastric pain, nausea and vomiting, leukocytosis, elevated lipase and amylase, and hypocalcemia are all consistent with acute pancreatitis. These findings align with the pathophysiology of pancreatitis, characterized by inflammation leading to severe abdominal pain and metabolic disturbances.
B: Gray-blue discoloration of the flanks indicates potential retroperitoneal bleeding, commonly associated with pancreatitis but not a primary symptom of cholecystitis.
D: Leukocytosis can occur in both conditions, yet it is more typical in cholecystitis due to infection rather than the inflammatory process of pancreatitis.
F: Hypocalcemia occurs in acute pancreatitis due to fat necrosis and calcium sequestration, while cholecystitis does not typically cause electrolyte imbalances.
The emergency department (ED) nurse is caring for a 45-year-old male client.
Item 6 of 6
Laboratory & Imaging Results
0630
Exam: CT Abdomen and Pelvis with IV Contrast
Indication: Acute onset of epigastric abdominal pain, nausea, vomiting.
Findings:
Pancreas: Diffuse enlargement of the pancreas with heterogeneous enhancement. Peripancreatic fat stranding and inflammatory changes are present, most pronounced around the pancreatic head and body. No evidence of necrosis at this time. No discrete mass or cystic lesion noted. Biliary system: Gallbladder is distended with no wall thickening or pericholecystic fluid. No gallstones visualized. Common bile duct is normal in caliber (~5 mm). Liver, spleen, kidneys, and adrenal glands: Normal in appearance. No focal lesions. Bowel: No obstruction or bowel wall thickening noted.
Impression:
Imaging findings are consistent with acute interstitial edematous pancreatitis.
No evidence of pancreatic necrosis or pseudocyst formation at this time.
Nurses’ Notes
0600: The client reports sudden, severe epigastric pain. He has a history of chronic alcohol use disorder (30+ years), GERD, and hypertension. His home medications include pantoprazole and lisinopril. Upon assessment, the client is noted to be alert and oriented x4. He is mildly diaphoretic, with pulses 2+ and regular. Abdomen is distended, guarding on palpation, diminished bowel sounds, and no stool in the last 24 hours. He reports nausea and vomiting, and his pain is worse after eating fatty foods, rated 7/10 and radiating to his back. Breath sounds slightly diminished bilaterally, no adventitious sounds, denies cough or dyspnea. He reports heavy alcohol intake two days ago. Fingerstick glucose is 145 mg/dL (8.06 mmol/L) [70-110 mg/dL; 4-6 mmol/L]. Temperature is 101.3°F (38.5°C), heart rate of 112 bpm, respiratory rate of 24 breaths/min, blood pressure of 98/64 mmHg, and oxygen saturation of 95% on room air.
0630: Physician confirmed the diagnosis of acute pancreatitis based on clinical presentation, laboratory findings, and imaging studies.
1030: Client receiving LR at 150 mL/hr, calcium replacement completed. Urine output over the last 4 hours is 80 mL of dark amber urine. The client reports increased thirst. The abdomen continues to be distended with diminished bowel sounds. He reports that nausea has improved after receiving PRN medication. Increased edema noted in the lower extremities.
Orders
0630
• Ondansetron 4mg IV q6h PRN
• Calcium gluconate 2g IV over 5-10 minutes
• Lactated Ringer’s solution continuous infusion IV rate of 150mL/hr
![The nurse knows that the client's condition is improving when they report a reduction in [condition]...](https://nurselytic.com/library/uploads/QSTN 21 Gastro.png)
The nurse knows that the client's condition is improving when they report a reduction in [condition].
Rationale:
Pain levels decreasing indicates the client’s condition is improving. The client has reported that the nausea has improved after receiving medication, suggesting effective pain management and recovery from acute pancreatitis symptoms.
A: Urine output Reduction in urine output may indicate worsening renal function or dehydration, which does not signify improvement in the client's overall condition during acute pancreatitis.
C: Muscle strength Muscle strength is not a primary concern in acute pancreatitis; it does not directly reflect the progression or resolution of the client’s abdominal condition.
D: None of the above Selecting this option disregards the significance of pain reduction as a key indicator of improvement in the client's condition following acute pancreatitis treatment.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 19-year-old male client.
Item 1 of 1
Nurses' Notes
0555: Client presents with abdominal pain, nausea, and some vomiting. The client's parents report that his symptoms started two nights ago and originated in the right lower quadrant. Overnight, his symptoms significantly intensified, and he developed a fever and chills. On assessment, the client's skin is hot and pale. Lung sounds are clear, and apical pulse is regular. Bowel sounds are absent in all quadrants. Abdomen is distended and rigid with guarding. Generalized abdominal pain was reported and rated 8/10 on the Numerical Rating Scale. He states that his abdominal pain increases with cough or movement and is relieved by bending the right hip. Vital signs: T 104°F (40°C), P 116, RR 21, BP 110/76, pulse oximetry reading 96% on room air. He has a medical history of iron deficiency anemia.
Laboratory Results
white blood cell (WBC) count: 21,000 mm3 [5,000–10,000/mm3]
hemoglobin: 13.9 g/dL [14–18 g/dL]
hematocrit: 41.7% [42%–52%]
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet.
B
Peritonitis, diverticulitis, appendicitis, gastroenteritis.
C
Lung sounds, pulse, temperature, hemoglobin and hematocrit.
Rationale:
Appendicitis. The client's symptoms, including severe abdominal pain in the right lower quadrant, fever, and elevated white blood cell count, strongly indicate appendicitis, a common acute surgical emergency requiring prompt management.
A: Insert a peripheral venous access device (VAD), obtain a stool specimen for culture and sensitivity (C & S), prepare the client for surgery, request an order for a clear liquid diet. Multiple actions focus on unnecessary tests rather than immediate surgical intervention for appendicitis.
C: Lung sounds, pulse, temperature, hemoglobin and hematocrit. While monitoring vital signs is essential, hemoglobin and hematocrit do not directly address the acute complications of appendicitis, which primarily involves abdominal assessment.
The nurse is assessing a client with suspected acute cholecystitis. Which of the following findings would support a diagnosis of acute cholecystitis?
Rationale:
Increased white blood cell count (WBC) supports a diagnosis of acute cholecystitis. This finding indicates an inflammatory response, commonly seen in conditions like acute cholecystitis due to infection or irritation of the gallbladder.
A: Decreased serum bilirubin indicates a lack of biliary obstruction or liver dysfunction, which does not align with the inflammatory nature of acute cholecystitis.
B: Increased high density lipoprotein cholesterol (HDL-C) suggests better lipid metabolism and cardiovascular health, unrelated to the inflammatory processes involved in acute cholecystitis.
C: Decreased serum aminotransferases typically reflect reduced liver injury or dysfunction, not indicative of the inflammation associated with acute cholecystitis.
The nurse is caring for a client receiving total parenteral nutrition (TPN) through a central line. The nurse plans on taking which appropriate action?
Rationale:
B: Weighing the client in the morning before the first void is essential as it provides an accurate baseline weight, crucial for monitoring fluid balance and nutritional status in patients receiving TPN.
A: Inserting an indwelling urinary catheter does not directly relate to monitoring a client on TPN and may introduce unnecessary risks of infection or complications.
C: Placing a mask on the client before changing the central line dressing is a safety measure, but it does not address the primary need for weight monitoring in TPN patients.
D: Establishing continuous cardiac monitoring may be necessary in certain cases, but it does not specifically relate to the immediate care actions required for a patient receiving TPN.
The nurse is teaching a client about their newly established colostomy. Which of the following statements by the client would require follow-up?
Rationale:
D: I should clean the skin around my stoma with rubbing alcohol. Using rubbing alcohol can irritate the skin, leading to discomfort and potential complications. Proper cleaning should involve gentle soap and water to maintain skin integrity and prevent infection.
A: I will call my primary healthcare provider (PHCP) immediately if my stoma becomes bluish. This response demonstrates good awareness of potential complications, indicating the client understands the need for prompt medical attention.
B: I should slowly introduce high-fiber foods in my diet. Gradually incorporating high-fiber foods is advisable to allow the digestive system to adjust, minimizing the risk of complications such as blockages.
C: I must always wear a pouch over my stoma. While wearing a pouch is essential for managing a colostomy, stating it must always be worn does not allow for necessary care and maintenance.
The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include?
Rationale:
C: It will be important to reduce the stress in your life. Stress management is crucial for individuals with peptic ulcer disease, as stress can exacerbate symptoms and hinder healing. Reducing stress can lead to improved outcomes and overall well-being for the client.
A: You should take aspirin if you have mild aches or pains. Aspirin can irritate the gastric lining and worsen peptic ulcers, making it unsuitable for this condition.
B: You will need to consume liquids one hour after each meal. This recommendation does not align with typical dietary advice for peptic ulcer management, where timing and types of liquids are more critical.
D: Take your prescribed omeprazole with food. Omeprazole is often more effective when taken before meals, as it reduces stomach acid production, which is essential for ulcer healing.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
Rationale:
Alprazolam should be clarified with the primary healthcare provider. This medication is a benzodiazepine that can exacerbate hepatic encephalopathy and worsen the client's neurological status, posing significant risks.
B: Rifaximin This antibiotic helps reduce ammonia-producing bacteria in the gut, effectively managing hepatic encephalopathy and improving mental status, making it a suitable choice for the client.
C: Lactulose This osmotic laxative aids in decreasing serum ammonia levels by promoting bowel movements, thus addressing symptoms of hepatic encephalopathy effectively and enhancing the client’s overall condition.
D: Spironolactone This diuretic is beneficial for managing ascites by promoting fluid excretion, which is essential in treating the client’s fluid overload without further complicating hepatic encephalopathy.
The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has
Rationale:
Rising aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels indicate potential liver dysfunction or transplant rejection, making this a critical finding that requires immediate communication with the healthcare provider.
A: An increase in oral temperature from 97.8°F (36.6°C) to 98.6°F (37°C) represents a minor variation and is not significant enough to warrant urgent notification to the HCP at this stage.
C: A moderate amount of serosanguinous drainage to the incision could be expected post-surgery and does not typically suggest an immediate complication requiring the HCP’s intervention.
D: Nausea following the administration of oral pain medication may occur commonly and is usually manageable, thus not necessitating prompt reporting to the healthcare provider in this context.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a client with liver cirrhosis
Item 1 of 1
Nurses' Note
57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.
Vital Signs
• Oral Temperature 101 o F (38.3o C)
• Heart rate 94/minute
• Respirations 24/minute
• Blood pressure 104/68 mm Hg
• Oxygen saturation 95% on room air
Medical History
• Hepatitis C
• Liver cirrhosis
• Substance use disorder
• Hyperlipidemia
Which assessment findings require follow-up? Select all that apply.
Rationale:
Labored breathing, elevated respiratory rate, and increased oral temperature indicate potential complications in a client with liver cirrhosis. These findings suggest respiratory distress and possible infection, necessitating further assessment and intervention to prevent deterioration.
A: Jaundice This is a common symptom of liver cirrhosis, indicating liver dysfunction but not necessarily requiring immediate follow-up.
C: Hypoactive bowel sounds While concerning, they can occur in cirrhosis without immediate implications for follow-up, especially if the patient is stable otherwise.
F: Yellow sclera This symptom, similar to jaundice, is typical in liver disease and does not indicate an acute change that requires urgent follow-up.
The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?
Rationale:
B: Right lateral. Positioning the client in the right lateral position after a liver biopsy helps to apply pressure to the biopsy site, minimizing bleeding and promoting hemostasis effectively.
A: Supine. Remaining supine does not provide the necessary pressure on the liver biopsy site, potentially increasing the risk of bleeding and complications post-procedure.
C: Sitting position with legs dangling off the edge of the bed. This position lacks the stability and pressure required on the biopsy site, which may hinder proper recovery and increase bleeding risks.
D: Left lateral. Placing the client in left lateral position does not apply pressure to the liver area, thus failing to effectively promote hemostasis and protect the biopsy site from complications.
The health care provider (HCP) places an order to administer gentamicin intravenously to a client with acute diverticulitis. It is important the nurse knows that intravenous gentamicin is administered:
Rationale:
Gentamicin is administered as an IV infusion over 30 minutes to two hours to ensure proper drug absorption, minimize potential side effects, and maintain therapeutic levels in patients with acute diverticulitis.
A: Over one minute via IV push. Administering gentamicin too quickly can lead to toxicity and adverse reactions, which are avoided by proper infusion timing.
B: Over two minutes via IV push. This rapid administration does not allow sufficient time for the medication to be absorbed safely, risking harmful side effects.
C: As an IV infusion over 15-20 minutes. While this duration is shorter than recommended, gentamicin requires a longer infusion time to enhance efficacy and reduce toxicity risks.
The nurse is caring for a postoperative client who underwent abdominal surgery and is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse notes that the client is sedated but still complaining of severe pain. What is the most appropriate action for the nurse to take?
Rationale:
Notify the healthcare provider.
The client’s sedation alongside persistent severe pain indicates potential complications or insufficient analgesia, requiring professional assessment and intervention to ensure the patient's safety and pain relief strategies are effectively adjusted.
A: Increase the PCA dosage. This approach may not address the root cause of the inadequate pain control and could exacerbate sedation and respiratory depression risks.
B: Administer a non-opioid analgesic. While adjunct medications can help, they may not sufficiently manage severe pain in a postoperative patient who is already on PCA morphine.
C: Discontinue PCA and Administer Intramuscular (IM) Morphine. Switching methods without professional guidance could lead to ineffective pain management or further complications, thus requiring provider involvement first.
The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.
Rationale:
Request an order for an antibiotic, notify the physician, and obtain an order for blood cultures. These actions are essential to address the signs of infection indicated by fever, purulent drainage, and erythema at the surgical site. Prompt intervention is crucial for preventing further complications and ensuring proper management of the patient's postoperative condition.
C: Ambulate the client to the bedside chair. While mobility is important, the presence of infection symptoms necessitates prioritizing medical interventions over ambulation to ensure safety and effective treatment.
E: Increase the nasal cannula oxygen to 4 L/minute. The client's oxygen saturation is adequate at 95%, thus increasing oxygen delivery is unnecessary and may lead to complications or patient discomfort without addressing the infection.
The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
Rationale:
McBurney's point tenderness is a sign of appendicitis, and the client may have an elevated white blood cell count (WBC).
McBurney's point tenderness indicates inflammation of the appendix, and elevated WBC levels reflect the body's response to infection. Both signs are clinically significant in diagnosing appendicitis and provide essential information for appropriate treatment.
B: Appendicitis is more common among males. While appendicitis can occur in both genders, it does not have a significant predilection for males over females.
C: A low carbohydrate diet is a risk factor for appendicitis. Dietary factors have not been conclusively linked to appendicitis risk, making this statement unsupported by current medical understanding.
D: Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography. This procedure primarily assesses bile and pancreatic ducts, not the appendix, making it unsuitable for diagnosing appendicitis.
A nurse is caring for a client with ulcerative colitis who has experienced severe diarrhea for the past 24 hours. When assessing the client, the nurse should watch for signs of which of the following?
Rationale:
A: Malnutrition
Severe diarrhea in ulcerative colitis can lead to significant nutrient loss, making malnutrition a critical concern. The body’s inability to absorb essential vitamins and minerals exacerbates this risk.
B: Metabolic acidosis
While diarrhea can affect pH balance, the prime issue in ulcerative colitis is nutrient depletion rather than acid-base imbalance. Thus, metabolic acidosis is not the immediate focus in this scenario.
D: Malabsorption
Although malabsorption can occur with ulcerative colitis, the acute symptom of severe diarrhea highlights immediate nutrient loss, making malnutrition the more pressing concern for the client’s current condition.
The nurse is caring for a client who recently had a partial gastrectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order?
Rationale:
Cyanocobalamin. After a partial gastrectomy, patients often experience vitamin B12 deficiency due to altered absorption. Cyanocobalamin is a vital supplement to prevent anemia and neurological complications associated with this deficiency.
B: Metoclopramide. This medication primarily addresses nausea and gastrointestinal motility issues, which may not be a priority after gastrectomy, where nutrient absorption and vitamin supplementation are more critical.
C: Sucralfate. Sucralfate is used to protect the stomach lining from ulcers, but after partial gastrectomy, the focus shifts to managing nutrient absorption and vitamin deficiencies, not ulcer prevention.
D: Hydroxyzine. This antihistamine is primarily utilized for anxiety and allergies, which do not directly relate to the postoperative needs of a patient recovering from a gastrectomy.
The nurse is caring for a client with advanced liver cirrhosis receiving prescribed medications. Which medications would the nurse clarify with the primary healthcare provider (PHCP)? Select all that apply.
Rationale:
Isoniazid, Valproic Acid, and Amiodarone are medications that require clarification due to their potential hepatotoxicity and interactions with liver function, which are critical considerations in clients with advanced liver cirrhosis.
D: Lithium This medication primarily affects kidney function and does not have significant implications for liver health, making it less concerning in patients with advanced liver cirrhosis.
E: Thiamine A vital nutrient, thiamine is often administered to support patients with liver conditions, particularly to prevent complications, thus posing no risk in this scenario.
The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure?
Rationale:
Polyethylene glycol 3350. This osmotic laxative is specifically prescribed to cleanse the bowel prior to a colonoscopy, ensuring that the colon is clear for optimal visualization during the procedure.
A: Docusate. This stool softener does not effectively prepare the bowel for a colonoscopy, as it primarily aids in softening existing stool rather than promoting complete bowel evacuation.
B: Loperamide. This medication is an antidiarrheal that slows intestinal movement, which contradicts the goal of achieving a cleansed bowel, essential for clear visibility during a colonoscopy.
D: Famotidine. As an H2 antagonist, famotidine reduces stomach acid but does not play any role in preparing the colon for a colonoscopy, making it unsuitable for this context.