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Questions and Answers
- 1.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
- A.
Notify the health care provider (HCP).
- B.
Administer the prescribed pain medication.
- C.
Call and ask the operating room team to perform surgery as soon as possible.
- D.
Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
Correct Answer
A. Notify the health care provider (HCP).Explanation
On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.Rate this question:
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- 2.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis ?Select all that apply.
- A.
Diarrhea.
- B.
Black, tarry stools.
- C.
Hyperactive bowel sounds.
- D.
Gray-blue color at the flank.
- E.
Abdominal guarding and tenderness
- F.
Left upper quadrant pain with radiation to the back.
Correct Answer(s)
D. Gray-blue color at the flank.
E. Abdominal guarding and tenderness
F. Left upper quadrant pain with radiation to the back.Explanation
Grayish-blue discoloration at the flank is known as Grey-Turner’s sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.Rate this question:
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- 3.
The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.
- A.
Nuts.
- B.
Corn.
- C.
Liver.
- D.
Apples.
- E.
Lentils.
- F.
Bananas.
Correct Answer(s)
A. Nuts.
C. Liver.
E. Lentils.Explanation
Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of functionof the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.Rate this question:
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- 4.
A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
- A.
Malaise.
- B.
Dark stools.
- C.
Weight gain.
- D.
Left upper quadrant discomfort.
Correct Answer
A. Malaise.Explanation
Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.Rate this question:
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- 5.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify?
- A.
Leg exercises.
- B.
Early ambulation.
- C.
Irrigating the nasogastric tube.
- D.
Coughing and deep-breathing exercises.
Correct Answer
C. Irrigating the nasogastric tube.Explanation
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically prescribed by the health care provider. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.Rate this question:
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Current Version
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Mar 22, 2023Quiz Edited by
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Oct 09, 2018Quiz Created by
Hemo1080