MedSurg: Prioritization Ch 5 GI

The charge nurse is reviewing the morning laboratory results. Which data should the charge nurse report to the HCP via telephone? 1. The client who is 4 hours postoperative for gastric lap banding with a white blood cell (WBC) count of 15,000 mm. 2. The client who is 1 day postoperative total colectomy with creation of an ileal conduit who has a hemoglobin and hematocrit level of 12/36. 3. The client who is 4 days postoperative for gastric bypass surgery whose fasting blood glucose level is 180 mg/dL. 4. The client who is 8 hours postoperative for exploratory laparotomy who has a serum potassium level of 4.5 mEq/L.

Correct answer: 1 1. Because a client undergoing an elective procedure such as a gastric lap banding is usually healthy prior to the surgery, an elevated postoperative WBC count—which this client has—may indicate infection and, therefore, requires notifying the HCP. 2. The H&H of 12/36 is within normal limits; therefore, this laboratory result does not warrant intervention. 3. The glucose level is elevated, but many clients who are overweight have diabetes. This client must be at least 50 pounds overweight to have gastric bypass surgery. 4. A serum potassium level of 4.5 mEq/L is within normal limits; therefore, this does not warrant notifying the healthcare provider.

The client 1 day postoperative abdominal surgery has an evisceration of the wound. Which intervention should the nurse implement first? 1. Place sterile normal saline gauze on the eviscerated area. 2. Reinforce the abdominal dressing with an ABD pad. 3. Assess the client's abdominal bowel sounds. 4. Place the client in the left lateral position.

Correct answer: 1 1. Evisceration is the removal of viscera (internal organs, especially those in the abdominal cavity). If the bowels protrude from the abdominal incision, the nurse must apply sterile normal saline gauze and then notify the client's surgeon. 2. The nurse can place an ADB pad on the normal sterile saline gauze. 3. The nurse can assess the bowel sounds, but not prior to applying sterile normal saline gauze. 4. The client should be placed in the supine position; the left lateral position will not affect the client's abdominal evisceration.

Which nursing problem is the highest priority for the client diagnosed with gastroenteritis from staphylococcal food poisoning? 1. Fluid and electrolyte imbalance. 2. Alteration in bowel elimination. 3. Nutrition, altered: less than body requirements. 4. Oral mucous membrane, altered.

Correct answer: 1 1. Fluid and electrolyte imbalance is priority because of the potential for metabolic acidosis and hypokalemia, which are both life threatening, especially in the elderly. 2. The client will have diarrhea, but it is not priority over fluid and electrolyte imbalance. 3. The client will probably be NPO and will not want to eat, but this diagnosis is not priority over fluid and electrolyte imbalance. 4. The client's oral mucous membranes may be dry due to vomiting and diarrhea, but it is not priority over fluid and electrolyte imbalance.

Which task should the nurse in the long-term care facility delegate to the unlicensed assistive personnel (UAP)? 1. Assist the resident up in a wheelchair for meals. 2. Assess the incontinent client's perianal area. 3. Discuss requirements with the client for going out on a pass. 4. Explain how to care for the client's colostomy to the family.

Correct answer: 1 1. Getting a resident up in a wheelchair for meals is an appropriate delegation to an unlicensed assistive personnel (UAP). This task does not require nursing judgment. 2. Assessing an incontinent client's perianal area requires nursing judgment and cannot be delegated to the UAP. 3. Discussing requirements with a client for going out on a pass should be done by the nurse responsible for completing the required documentation and providing any medication that the resident should take along. 4. Explaining colostomy care is teaching, and the RN cannot ask the UAP to teach.

The nurse has received the a.m. shift report. Which client should the nurse assess first? 1. The client with peptic ulcer disease who is complaining of acute epigastric pain. 2. The client with acute gastroenteritis who is upset and wants to go home. 3. The client with inflammatory bowel disease who is receiving total parental nutrition. 4. The client with hepatitis B who is complaining and who is jaundiced and anorexic.

Correct answer: 1 1. Pain should be assessed, even if it is expected for the client's diagnosis, if the other clients are stable. 2. The nurse needs to talk to this client, but should assess the client with pain first. 3. The client with IBD who is receiving total parental nutrition is stable and would not be assessed first. 4. The client with hepatitis B would be expected to be jaundiced and anorexic, so this client would not be assessed first.

The staff nurse is working with a colleague who begins to act erratically and is loud and argumentative. Which action should be taken by the nurse? 1. Ask the supervisor to come to the unit. 2. Determine what is bothering the nurse. 3. Suggest the nurse go home. 4. Smell the nurse's breath for alcohol.

Correct answer: 1 1. The actions of the colleague indicate possible drug or alcohol impairment. The staff nurse is not in a position of authority to require the potentially impaired nurse to submit to a drug test. The administrative supervisor should assess the situation and initiate the appropriate follow-up. The nurse must make sure an impaired nurse is not allowed to care for clients. 2. The nurse is not a counselor, and a staff nurse should not attempt to confront an impaired colleague. 3. The administrative supervisor and the charge nurse are the only staff members who have the authority to send a nurse home. 4. The nurse should not attempt to determine the cause of the behavior. This is outside the nurse's authority.

The client who is morbidly obese is 8 hours postoperative gastric bypass surgery. Which nursing intervention is of the greatest priority? 1. Instruct the client to use the incentive spirometer. 2. Weigh the client daily in the same clothes and at the same time. 3. Apply sequential compression devices to the client's lower extremities. 4. Assist the client to sit in the bedside chair.

Correct answer: 1 1. The client that is morbidly obese will have a large abdomen that prevents the lungs from expanding and predisposes the client to respiratory complications. Having the client use an incentive spirometer will help prevent respiratory complications. 2. The client may be weighed daily, but this is not priority over respiratory complications. 3. Preventing deep vein thrombosis is an important intervention, but oxygenation is priority. 4. The nurse should get the client out of the bed as soon as possible to help prevent deep vein thrombosis, but not priority over oxygenation.

Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the long-term care nurse? 1. The UAP is giving the client with a gastrostomy tube a glass of water. 2. The UAP is ambulating the client outside using a safety belt. 3. The UAP is assisting the client with putting a jigsaw puzzle together. 4. The UAP is giving a back rub to the client who is on bed rest.

Correct answer: 1 1. The client with a gastrostomy tube cannot eat or drink oral fluids; therefore, this behavior warrants intervention by the nurse. 2. At the long-term care center the clients are allowed to go outside and the unlicensed assistive personnel (UAP) ambulating the client with a safety belt is appropriate behavior. 3. Assisting the client with an activity is an appropriate behavior by the UAP in a long-term care center. 4. Giving a back rub to a client on bed rest is a wonderful thing for the UAP to do for the client.

The client is diagnosed with gastroenteritis. Which laboratory data warrants immediate intervention by the nurse? 1. A serum sodium level of 152 mEq/L. 2. An arterial blood gas of pH 7.37, PaO2 95, PaCO2 43, HCO3 24. 3. A serum potassium level of 4.8 mEq/L. 4. A stool sample that is positive for fecal leukocytes.

Correct answer: 1 1. The normal serum sodium level is 135-145 mEq/L; this sodium level is elevated, indicating the client is dehydrated, which warrants intervention by the nurse. 2. These are normal arterial blood gas results; therefore, the nurse would not need to intervene. 3. The normal serum potassium level is 3.5-5.5 mEq/L; therefore, this laboratory information does not warrant intervention by the nurse. 4. A stool specimen showing fecal leukocytes would support the diagnosis of gastroenteritis and not warrant immediate intervention by the nurse.

The nurse is transcribing the HCP's orders for a client who is scheduled for an emergency appendectomy and is being transferred from the emergency department (ED) to the surgical unit. Which order should the nurse implement first? 1. Obtain the client's informed consent. 2. Administer 2 mg of IV morphine, every 4 hours, PRN. 3. Shave the lower right abdominal quadrant. 4. Administer the on-call IVPB antibiotic.

Correct answer: 1 1. The nurse must first obtain the operative permit, or determine whether it has been signed by the client, prior to implementing any other orders. 2. The client cannot give informed consent after receiving pain medication; therefore, administration of morphine cannot be implemented first. 3. The operating room staff usually performs shave preps, but the nurse would not implement this prior to medicating the client. 4. The on-call IVPB is not administered until the operating room (OR) is prepared for the client. New standards recommend that the prophylactic IVPB antibiotic be administered within 1 hour of opening the skin during a surgical procedure.

The unlicensed assistive personnel (UAP) tells the nurse angrily, "You are the worst nurse I have ever worked with and I really hate working with you." Which action should the nurse implement first? 1. Don't respond to the comment and appraise the situation. 2. Tell the UAP to leave the unit immediately. 3. Report this comment and behavior to the charge nurse. 4. Explain to the UAP that he or she cannot talk to the primary nurse like this.

Correct answer: 1 1. The nurse should first appraise the situation and not do anything. This is the pivotal point at which the nurse can return the anger or reappraise the situation. The most important action to take is to empathize with the UAP and to try to find out the provocation for the behavior. 2. The primary nurse could tell the UAP to leave the unit, but this is responding to the anger and not the reason for the anger. 3. The comment may need to be reported to the charge nurse, but not until the primary nurse can determine what caused the comment. The UAP may be upset about something else entirely. 4. This is not the first action when dealing with someone who is angry. This comment may cause further angry behavior by the UAP and will not diffuse the situation. The nurse is the professional person and should control the situation.

The client is being prepared for a colonoscopy in the day surgery center. The charge nurse observes the primary nurse instructing the unlicensed assistive personnel (UAP) to assist the client to the bathroom. Which action should the charge nurse implement? 1. Take no action because this is appropriate delegation. 2. Tell the UAP to obtain a bedside commode for the client. 3. Discuss the inappropriate delegation of the nursing task. 4. Document the situation in an adverse occurrence report.

Correct answer: 1 1. The primary nurse's instruction to the UAP to assist the client to the bathroom is an appropriate delegation that ensures the safety of the client. It requires no action by the charge nurse. 2. There is no information in the stem that indicates the client needs a bedside commode; therefore, this is not an appropriate action. 3. The UAP can assist a client who is stable to ambulate; therefore, this is not inappropriate delegation. 4. An adverse occurrence report is completed whenever potential or actual harm has come to the client. Ambulating the client with assistance is not harmful.

The client tells the nurse in the bariatric clinic, "I have tried to lose weight on just about every diet out there but nothing works." Which statement is the nurse's best response? 1. "Which diets and modifications have you tried?" 2. "How much weight are you trying to lose?" 3. "This must be difficult. Would you like to talk?" 4. "You may need to get used to being overweight."

Correct answer: 1 1. This is an assessment question and should be asked to determine what the client has attempted has been unsuccessful. 2. The amount of weight loss desired is not as important as assessment of previous unsuccessful strategies. 3. This is a therapeutic statement, but the nurse should assess the client. 4. This statement is not helpful, and the nurse working in a bariatric clinic should know that there are many options for weight loss, including surgery.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia. 2. Request the UAP change the linens for the 89-year-old client with fecal incontinence. 3. Tell the UAP to assist the 54-year-old client with a bowel management program. 4. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis.

Correct answer: 1 1.The nurse should not delegate to the UAP feeding a client who is not stable and at risk for complications during feeding, as a result of dysphagia. This requires judgment that the UAP is not expected to possess. 2. UAPs can change linens for clients who are incontinent; therefore, this task could be delegated to a UAP. 3. The UAP can assist the client to the bathroom and document the results of the attempt. 4. The UAP can obtain the vital signs on a stable client.

The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure? 1. The cardiac catheterization department. 2. The dietary department. 3. The nuclear medicine department. 4. The hospital laboratory department.

Correct answer: 2 1. Because this procedure is performed in the radiology department and is testing the gastrointestinal system, the cardiac catheter lab does not need to be informed of the procedure. 2. The client must be NPO for 8 to 10 hours before the procedure. Therefore, the dietary department should be notified to hold the meal trays. 3. The procedure is performed using barium or Gastrografin, neither of which contains any nuclear material. The nuclear medicine department does not need to be informed of the procedure. 4. The procedure does not involve the clinical laboratory; therefore, this department does not need to be notified.

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first? 1. The client who has been vomiting for 2 days and has an ABG of pH 7.47, PaO2 95, PaCO2 44, HCO3 30. 2. The client who is 8 hours postoperative for splenectomy and who is complaining of abdominal pain, rating it as a 9 on a pain scale of 1 to 10. 3. The client who is 12 hours postoperative abdominal surgery and has dark green bile draining in the nasogastric tube. 4. The client who is 2 days postoperative for hiatal hernia repair and is complaining of feeling constipated.

Correct answer: 2 1. The ABGs reflect metabolic alkalosis, which is expected in a client who has excessive vomiting; therefore, this client would not be assessed first. 2. Pain is priority because the nurse must determine if this is expected postoperative pain or a complication of the surgery. This client should be assessed first. 3. Dark green bile should be draining from the client's nasogastric tube; therefore, this client should not be assessed first. 4. The client who is complaining of being constipated would not be priority over a client with surgical pain.

The unlicensed assistive personnel (UAP) notifies the charge nurse that the male client is angry with the care he is receiving and is packing to leave the hospital. Which intervention should the charge nurse implement first? 1. Ask the client's nurse why the client is upset. 2. Discuss the problem with the client. 3. Notify the healthcare provider (HCP). 4. Have the client sign the against medical advice (AMA) form.

Correct answer: 2 1. The charge nurse should discuss the client's anger with the client immediately because the client is preparing to leave the hospital. The charge nurse can talk with the primary nurse after talking with the client. 2. This is the first action for the charge nurse. The client is preparing to leave, and a delay in going to the client's room could result in the client leaving before the situation can be resolved. 3. The HCP should be notified, but the charge nurse should assess the situation first. 4. The client will be asked to sign the against medical advice form if he insists on leaving, but the charge nurse should attempt to resolve the situation successfully first.

The charge nurse notices a nurse recapping a needle in a client's room. Which action should the charge nurse take first? 1. Tell the nurse not to recap the needle. 2. Quietly ask the nurse to step into the hall. 3. Reprimand the nurse for not following procedure. 4. Notify the house supervisor of the nurse's behavior.

Correct answer: 2 1. The charge nurse should stop the nurse from recapping the needle, but not in front of the client. 2. The charge nurse should not reprimand the nurse in front of the client or client's family. The charge nurse should ask the nurse to step into the hall, where the client cannot hear. 3. Reprimanding the nurse is not the first action. 4. Notifying the house supervisor is not the first action.

The nurse is caring for the following clients on a surgical unit. Which client should the nurse assess first? 1. The client with an inguinal hernia repair who has a urine output of 160 mL in 4 hours. 2. The client with an emergency appendectomy who was transferred from PACU. 3. The client who is 4 hours postoperative abdominal surgery who has flatulence. 4. The client who is 6 hours post-procedure colonoscopy and is being discharged.

Correct answer: 2 1. The client should urinate 30 mL/hour, so 160 mL in 4 hours is appropriate and the nurse should not assess this client first. 2. This client was just transferred from the Post Anesthesia Care Unit (PACU); therefore, the nurse should assess this client first to perform a baseline assessment and ensure the client is stable. 3. Flatulence, "gas," indicates the bowels are working, which is normal for a client with abdominal surgery, so this client should not be seen first. 4. The client being discharged would be stable and not a priority for the nurse.

The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse? 1. The client who has received three units of packed red blood cells (RBCs). 2. The client scheduled for an esophagogastroduodenoscopy in the morning. 3. The client with short bowel syndrome who has diarrhea and a K+ level of 3.3 mEq/L. 4. The client who has just returned from surgery for a sigmoid colostomy.

Correct answer: 2 1. This client is unstable and should not be assigned to a new graduate nurse. 2. This client is being prepared for a test in the morning and is the least acute of the clients listed. The new graduate should be assigned to this client. 3. This client is hypokalemic secondary to diarrhea and is at risk for cardiac dysrhythmias. This client should be assigned to a more experienced nurse. Short bowel syndrome is a malabsorption disorder caused by the surgical removal of the small intestine or rarely due to the complete dysfunction of a large segment of bowel. 4. A client returning from surgery with a sigmoid colostomy is at risk for postoperative complications and should be assigned to a more experienced nurse.

The nurse has received the morning shift report on a surgical unit in a community hospital. Which client should the nurse assess first? 1. The client who is 6 hours postoperative small bowel resection who has hypoactive bowel sounds in all four quadrants. 2. The client who is scheduled for an abdominal-peritoneal resection this morning and is crying and upset. 3. The client who is 1 day postoperative for abdominal surgery and has a rigid, hard abdomen. 4. The client who is 2 days postoperative for an emergency appendectomy and is complaining of abdominal pain, rating it as an 8 on a pain scale of 1 to 10.

Correct answer: 3 1. A client who is 6 hours postoperative abdominal surgery would be expected to have decreased bowel sounds; therefore, this client would not be assessed first. 2. Surgery is scary, and the client who is crying and upset should be assessed, but not prior to a potentially life-threatening surgical emergency. Psychosocial problems do not take priority over physiological problems. 3. A hard, rigid abdomen indicates peritonitis, which is a life-threatening emergency. This client should be assessed first. 4. The client who is 2 days postoperative and who is complaining of and rating pain as an 8 should be assessed, but the pain is not life threatening and, therefore, does not take priority over the patient with probable peritonitis.

The nurse is preparing clients for surgery. Which client has the greatest potential for experiencing complications? 1. The client scheduled for removal of an abdominal mass who is overweight. 2. The client scheduled for a gastrectomy who has arterial hypertension. 3. The client scheduled for an open cholecystectomy who smokes two packs of cigarettes per day. 4. The client scheduled for an emergency appendectomy who smokes marijuana on a daily basis.

Correct answer: 3 1. A client who is overweight and having abdominal surgery is not at a higher risk for postoperative complications than any other client. 2. The client's high blood pressure should be monitored closely and medications administered to decrease the hypertension, but this would not cause the client to have a higher risk for postoperative complications. 3. The location of the incision for a cholecystectomy, the general anesthesia needed, and a heavy smoking history make this client high risk for pulmonary complications. {The abdominal incision may put pressure on the diaphragm putting pt at risk for pneumonia, atelectasis, etc. Teach pt deep breathing/coughing, splinting, using IS, etc.} 4. Use of marijuana daily does not increase the risk of pulmonary complications for a client having gastric surgery.

The nurse and the unlicensed assistive personnel (UAP) are caring for a client on a medical unit who has difficulty swallowing and is incontinent of urine and feces. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Check the client's PEG feeding tube for patency. 2. Place DuoDERM wound care patches on the client's coccyx. 3. Apply non-medicated ointment to the client's perineum. 4. Suction the client during feeding to prevent aspiration.

Correct answer: 3 1. Checking the patency of a PEG feeding tube requires nursing judgment, and feeding the client through the tube is based on this judgment. The unlicensed assistive personnel (UAP) should not be asked to perform this task. 2. The nurse should assess the coccyx and the area where the DuoDERM should be placed. The UAP should not be asked to perform this task. 3. The UAP can apply non-medicated ointment to protect the client's perineum when bathing and changing the client's incontinence pads. This will protect the client from skin breakdown. 4. The nurse should not delegate suctioning during feeding to a UAP. This indicates the client is unstable.

The nurse is working in a digestive disease disorder clinic. Which nursing action is an example of evidence-based practice (EBP)? 1. Turn on the tap water to help a client urinate. 2. Use two identifiers to identify a client before a procedure. 3. Educate a client based on current published information. 4. Read nursing journals about the latest procedures.

Correct answer: 3 1. Many nurses follow this practice, but no research has been completed to support this practice. 2. This is part of the Joint Commission's Patient Safety Goals, not evidence-based practice. 3. Evidence-based practice is the conscientious use of current best evidence in making decisions about nursing care. Using the "evidence," or research, to teach a client is evidence-based practice. 4. Reading the journal is a step in EBP, but EBP requires using the information in practice.

The charge nurse is making assignments on a medical-surgical unit. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with lower esophageal dysfunction who is experiencing regurgitation. 2. The client diagnosed with Barrett's esophagitis who is scheduled for an endoscopy. 3. The client diagnosed with gastroesophageal reflux disease who has bilateral wheezes. 4. The client diagnosed with 1 day post-op hiatal hernia who has pain rated a 4 on a pain scale of 1 to 10.

Correct answer: 3 1. Regurgitation (effortless return of food or gastric contents from the stomach into esophagus or mouth) is a common manifestation of GERD; therefore, this client would not be assigned to the most experienced nurse. 2. Barrett's esophagitis is a complication of GERD; new graduates can prepare a client for a diagnostic procedure. 3. This client is exhibiting symptoms of asthma, a complication of GERD; therefore, the client should be assigned to the most experienced nurse. 4. Pain is expected with a surgical procedure and a less experienced nurse could administer pain medication.

Which behavior by the UAP warrants intervention by the home health (HH) nurse? The client tells the HH nurse the UAP: 1. Would not accept a birthday gift from the client. 2. Gave the client a vase of flowers from the UAP's garden. 3. Picked up the client's prescriptions from the pharmacy. 4. Cleaned the client's bathroom, including scrubbing the commode.

Correct answer: 3 1. Since the UAP cannot accept gifts or money from the client, this would not warrant an intervention. 2. The UAP can bring flowers to the client. This does not violate any rules. 3. The UAP should not take money from the client to pick up prescriptions and the UAP is not responsible for doing errands for the client. If money is missing or medications are missing, this could result in a difficult situation. The home health (HH) nurse should tell the UAP not to do this type of activity for the client. 4. Cleaning the house is not part of the UAP's job description, but this would not warrant intervention by the HH nurse.

Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse? 1. The UAP is refusing to feed the client diagnosed with acute diverticulitis. 2. The UAP would not place the client on the bedside commode who was on bed rest. 3. The UAP placed the client with a continuous feeding tube in the supine position. 4. The UAP placed sequential compression devices on the client who is on strict bed rest.

Correct answer: 3 1. The client diagnosed with acute diverticulitis should be NPO; therefore, the UAP should not feed a client. This action does not warrant immediate intervention. 2. The UAP should not allow the client on bed rest to use the bedside commode; therefore, this does not warrant immediate intervention by the nurse. 3. A client with a continuous feeding tube should be in the Fowler's or high-Fowler's position to prevent aspiration pneumonia. This action requires immediate intervention by the nurse. 4. The UAP can place sequential compression devices on a client; therefore, this does not warrant immediate intervention.

The female client, diagnosed with diverticulosis, called the home healthcare agency and told the nurse, "I am having really bad pain in my left lower stomach and I think I have a fever." Which action should the nurse take? 1. Recommend the client take an antacid and lie flat in the bed. 2. Instruct one of the nurses to visit the client immediately. 3. Tell the client to have someone drive them to the emergency room. 4. Ask the client what she has had to eat in the last 8 hours.

Correct answer: 3 1. The client is having signs/symptoms of diverticulitis, which can be potentially life threatening; therefore, the client should get medical assistance immediately. 2. The client needs to be seen by a medical doctor to be prescribed antibiotics; therefore, there is no reason for an HH nurse to visit the client. 3. The nurse must have knowledge of disease processes. The client is verbalizing signs of acute diverticulitis, which requires the client to be NPO and prescribed antibiotics. The client needs to receive immediate medical attention. 4. The client is verbalizing signs/symptoms of acute diverticulitis, which requires medical attention. It does not matter what the client has had to eat.

The charge nurse has completed report. Which client should be seen first? 1. The client diagnosed with ulcerative colitis who had five loose stools the previous shift. 2. The elderly client admitted from another facility who is refusing to be seen by the nurse. 3. The client with intractable vomiting who has tented skin turgor and dry mucous membranes. 4. The client with hemorrhoids who had spotting of bright red blood on the toilet tissue.

Correct answer: 3 1. The client with ulcerative colitis can have 10 to 12 loose stools a day; therefore, this client should not be seen first. {Pts with ulcerative colitis may have 10 to 20 bloody diarrhea stools per day, this is the most common symptom of UC} 2. This client should be assessed, but not priority over a client with a physiological problem. 3. This client has signs of dehydration, which is not expected when a client is vomiting. The client should remain hydrated even when the client is vomiting. 4. This is not normal, but it is expected for a client with hemorrhoids.

The client is diagnosed with esophageal bleeding. Which of the following assessment data warrants immediate intervention by the nurse? 1. The client's hemoglobin/hematocrit is 11.4/32. 2. The client's abdomen is soft to touch and non-tender. 3. The client's vital signs are T 99, AP 114, RR 18, B/P 88/60. 4. The client's nasogastric tube has coffee ground drainage.

Correct answer: 3 1. The client's H&H is not within normal limits, but remember: "Hemoglobin 9 think about transfusion time." This laboratory information does not warrant immediate intervention. 2. A soft, non-tender abdomen is expected and does not warrant immediate intervention by the nurse. 3. The client's apical pulse (AP) is above normal and the B/P is low, which are signs of hypovolemic shock, which warrants immediate intervention by the nurse. 4. Coffee ground drainage indicates "old blood," which would not be unexpected in the client who has esophageal bleeding.

The nurse is working in a community health clinic. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to take the client's history. 2. Request the UAP to document the client's complaints. 3. Ask the UAP to obtain the client's weight and height. 4. Tell the UAP to complete the client's follow-up care.

Correct answer: 3 1. The nurse cannot delegate any task requiring nursing judgment. Taking a client's history requires knowing which questions need to be asked to assess the client's problems. 2. Documenting the client's complaints is a nursing responsibility that the nurse must perform. It cannot be delegated to unlicensed assistive personnel (UAP). 3. The UAP can obtain the client's height and weight. This is the task the nurse should delegate. 4. The client's follow-up care may require teaching, judgment, or further assessment; therefore, the nurse should not delegate this action to a UAP. When delegating to a UAP, the nurse must provide clear, concise, and specific instructions. The nurse cannot delegate teaching.

The client who has had abdominal surgery is complaining of pain and tells the nurse, "I felt something pop in my stomach." Which intervention should the nurse implement first? 1. Check the client's apical pulse and blood pressure. 2. Determine the client's pain on a 1 to 10 pain scale. 3. Assess the client's surgical wound site. 4. Administer pain medication intravenously.

Correct answer: 3 1. The nurse should assess the client for hypovolemia, but the first intervention is to assess the client's surgical wound to determine if wound dehiscence has occurred. 2. The nurse should determine the client's pain, but not prior to determining the cause of the pain. 3. Assessing the surgical incision is the first intervention because this may indicate the client has wound dehiscence. 4. The nurse should not administer pain medication without assessing for potential complications first.

The client is experiencing severe diarrhea and a serum potassium level of 3.3 mEq/L. Which intervention should the nurse implement first? 1. Notify the client's healthcare provider. 2. Assess the client for leg cramps. 3. Place the client on cardiac telemetry. 4. Prepare to administer intravenous potassium.

Correct answer: 3 1. The nurse should notify the HCP, but it is not the first intervention. 2. The nurse should assess the client for leg cramps, indicating hypokalemia, but the nurse should first ensure the client's cardiac status is stable. 3. The client is at high risk for cardiac dysrhythmias, due to hypokalemia. The nurse should first assess the cardiac status, then implement other interventions. Remember Maslow's Hierarchy of Needs. 4. The client will need IV potassium, but this requires an HCP order; therefore, this intervention is not implanted first.

The nurse is caring for clients on a medical unit. Which task should the nurse implement first? 1. Change the abdominal surgical dressing for a client who has ambulated in the hall. 2. Discuss the correct method of placing Montgomery straps on the client with the UAP. 3. Assess the male client who called the desk to say he is nauseated and just vomited. 4. Place a call to the extended care facility to give the report on a discharged client.

Correct answer: 3 1. This client should be seen in a timely manner, but not before the client who is vomiting. 2. This can take some time and should not be hastily completed because the nurse must know the task is being done correctly before delegating it to a UAP. This should be done at a time arranged between the UAP and the nurse. 3. This client has experienced a physiological problem and the nurse must assess the client and the emesis to decide on possible interventions. 4. The nurse could call the extended care facility after assessing the client who has vomited and after dressing the client's leg.

The medical-surgical nurse has just received the a.m. shift report. Which client should the nurse assess first? 1. The client who has a paralytic ileus and has absent bowel sounds. 2. The client who is 2 days post-op abdominal surgery and has a soft, tender abdomen. 3. The client who is 6 hours postoperative and has an abdominal wound dehiscence. 4. The client who had a liver transplant and is being transferred to the rehabilitation unit.

Correct answer: 3 1. This client with a paralytic ileus would be expected to have absent bowel sounds; therefore, this client should not be assessed first. 2. The client who is postoperative abdominal surgery should have a soft, tender abdomen; therefore, this client should not be assessed first. 3. Wound dehiscence is the premature "bursting" open of a wound along surgical suture, and is an emergency that would require the nurse to assess this client first. 4. This client should be prepared for transfer to the rehabilitation unit, but not prior to assessing a client with a complication of surgery.

The nurse is preparing to administer morning medications to clients on a medical unit. Which medication should the nurse administer first? 1. Methylprednisolone (Solu-Medrol), a steroid, to a client diagnosed with Crohn's disease. 2. Donepezil (Aricept), an acetylcholinesterase inhibitor, to a client with dementia. 3. Sucralfate (Carafate), a mucosal barrier agent, to a client diagnosed with ulcer disease. 4. Enoxaparin (Lovenox), an anticoagulant, to a client on bed rest after abdominal surgery.

Correct answer: 3 1. This is a routine medication that has a time frame of 30 minutes before and after the scheduled time to be administered. This medication does not need to be the first medication administered. 2. Aricept can be administered within a 30-minute time frame. This medication does not need to be the first medication administered. 3. A mucosal barrier agent must be administered before the client eats in order for the medication to coat the gastric mucosa. This medication should be administered first. 4. Lovenox can be administered within the 30-minute time frame. This medication does not need to be the first medication administered.

The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task is most appropriate to assign/delegate? 1. Instruct the UAP to discontinue the client's total parenteral nutrition. 2. Ask the UAP to give the client 30 mL of Maalox for heartburn. 3. Tell the LPN to administer a bulk laxative to a client diagnosed with constipation. 4. Request the LPN to assess the abdomen of a client who has had complaints of pain.

Correct answer: 3 1. Total parenteral nutrition is an intravenous medication; the nurse cannot delegate medication administration to the UAP. 2. The nurse cannot delegate medication administration to the UAP. 3. The LPN can administer medications to a client. 4. The RN cannot assign assessment to the LPN.

The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client? 1. Obtain informed consent from the client for the diagnostic procedure. 2. Discuss the need to increase oral fluid intake after the procedure. 3. Explain to the client that he or she will have to drink a white, chalky substance. 4. Tell the client not to eat or drink anything prior to the procedure.

Correct answer: 4 1. A barium study of the upper GI system is an x-ray procedure and does not require the client to sign an informed consent form. 2. The barium can cause constipation after the procedure; therefore, the client should increase fluid intake, but this is not the priority intervention. 3. The client will have to drink a white, chalky substance, but the priority intervention is to make sure the client is NPO. 4. The test is a barium study of the upper GI system and requires the client's upper GI system to be empty. This client should be made NPO at least 8 to 10 hours before the test.

The nurse is planning the care of a client diagnosed with acute gastroenteritis. Which nursing problem is priority? 1. Altered nutrition. 2. Self-care deficit. 3. Impaired body image. 4. Fluid and electrolyte imbalance.

Correct answer: 4 1. Altered nutrition is a concern, but a client can live for several weeks on minimal intake. 2. Self-care deficit is a psychosocial problem; physiological problems have priority. 3. Impaired body image is a psychosocial problem; physiological problems have priority. 4. Fluid and electrolyte imbalance can cause cardiac dysrhythmias. This is the priority problem.

Which task is most appropriate for the home healthcare nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Instruct the UAP to give the herb ginkgo biloba to the client with Alzheimer's. 2. Ask the UAP to perform the tube feedings for a client with a gastrostomy tube. 3. Request the UAP to perform the daily colostomy irrigation for the client. 4. Tell the UAP to wash and dry the client's hair.

Correct answer: 4 1. Even though the client is not prescribed this medication by the healthcare provider, the nurse cannot delegate any type of medication administration to the unlicensed assistive personnel (UAP). 2. In some situations, the UAP may be able to perform tube feedings in the home, but the nurse should assign the least invasive procedure to the UAP. 3. In some situations, the UAP may be able to do colostomy irrigations in the home, but the nurse should assign the least invasive procedure to the UAP. 4. The UAP can wash and dry the client's hair, as this is the least invasive task, so this would be the most appropriate task for the nurse to delegate to the UAP.

Which client warrants immediate intervention from the nurse on the medical unit? 1. The client diagnosed with dyspepsia who has eructation and bloating. 2. The client diagnosed with pancreatitis who has steatorrhea and pyrexia. 3. The client with diverticulitis who has left lower quadrant pain and fever. 4. The client with Crohn's disease who has right lower abdominal pain and diarrhea.

Correct answer: 4 1. The nurse would expect the client with dyspepsia (upset stomach) to have eructation (belching) and bloating; therefore, this client does not warrant immediate intervention. 2. The nurse would expect the client with pancreatitis to have steatorrhea (fat, frothy stools) and pyrexia (fever); therefore, this client does not warrant immediate intervention. 3. The nurse would expect the client with diverticulitis to have left lower quadrant pain and fever; therefore, this client does not warrant immediate intervention. 4. The client with Crohn's disease should be asymptomatic, so pain and diarrhea warrant intervention by the nurse. Pain could indicate a complication.

The nurse is caring for a client diagnosed with peptic ulcer disease. Which assessment data would cause the client to require an immediate intervention by the nurse? 1. The client has hypoactive bowel sounds. 2. The client's output is 480 mL for 12-hour shift. 3. The client has T 98.6, AP 98, RR 22, B/P 102/78. 4. The client has coffee ground emesis.

Correct answer: 4 1. Hypoactive bowel sounds are not normal, but it would not warrant immediate intervention. As long as the bowels are moving, it is not an emergency. 2. The client should have 30 mL of urine output an hour; therefore, this information is normal and does not warrant immediate intervention. 3. These vital signs are normal; therefore, they do not warrant immediate intervention. 4. Coffee ground emesis indicates bleeding and old blood, and warrants intervention by the nurse. Further assessment is needed to determine if the client is hypovolemic and the HCP should be notified.

Which client should the nurse assess first after receiving the p.m. shift assessment? 1. The client with Barrett's esophagus who has dysphagia and pyrosis. 2. The client with proctitis who has tenesmus and passage of mucus through the rectum. 3. The client with liver failure who is jaundiced and has ascites. 4. The client with abdominal pain who has an 8-hour urinary output of 150 mL.

Correct answer: 4 1. The client with Barrett's esophagus is expected to have dysphagia (difficulty swallowing) and pyroisis (heartburn); therefore, this client would not be assessed first. 2. Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum. Symptoms are ineffectual straining to empty the bowels (tenesmus), diarrhea, rectal bleeding and possible discharge, involuntary spasms and cramping during bowel movements, left-sided abdominal pain, passage of mucus through the rectum, and anorectal pain. Since the signs/symptoms are expected, this client would not be assessed first. 3. Jaundice and ascites are expected in a client with liver failure; therefore, the nurse should not assess this client first. 4. The client has a urinary output of less than 30 mL/hr; therefore, this client may be going into renal failure and should be assessed first.

The client who is 2 days postoperative abdominal surgery has a hemovac drainage tube. Which assessment data indicates the Jackson-Pratt (JP) is functioning appropriately? 1. The hemovac is round and has 40 mL of fluid. 2. The drainage tube is pinned to the dressing. 3. The hemovac insertion site is pink and has no drainage. 4. The hemovac has suction and is compressed.

Correct answer: 4 1. The hemovac should be depressed, which indicates suction is being applied. The hemovac needs to be emptied and suction reapplied, which indicates the hemovac is not functioning appropriately. 2. The tube should be pinned to the dressing to prevent the client drain from accidentally being pulled out of the insertion site, but this does not indicate the hemovac is functioning appropriately. 3. The insertion site should be pink and without any signs of infection, which include drainage, warmth, and redness, but it does not indicate the hemovac is functioning appropriately. 4. The hemovac should be sunken in or depressed, indicating that suction is being applied, which indicates the hemovac is functioning appropriately. {Hemovac is a round drain that is compressed flat to provide suction to a draining wound. The capacity is larger. A JP drain has one function, to drain smaller amounts of fluid and blood from a surgical site. In both, the nurse should compress them to create negative pressure to help blood drain from the wound by gravity}