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sunnysummer sunnysummer
wrote...
6 years ago
A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find?
 
  a. Severe, steady right lower quadrant pain
  b. Abdominal pain associated with nausea and vomiting
  c. Marked peristalsis and hyperactive bowel sounds
  d. Abdominal pain that increases with knee flexion

Question 2

A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a client who has colon cancer. The client weights 132 lb. How many milligrams should the nurse administer?
 
  (Record your answer using a whole number.) _____ mg

Question 3

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.)
 
  a. Assess for proper placement of the tube every 4 hours.
  b. Flush the tube with water every hour to ensure patency.
  c. Secure the NG tube to the client's upper lip.
  d. Disconnect suction when auscultating bowel peristalsis.
  e. Monitor the client's skin around the tube site for irritation.

Question 4

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.)
 
  a. Using premoistened disposable wipes for perineal care
  b. Turning the client from right to left every 2 hours
  c. Using an antibacterial soap to clean after each stool
  d. Applying a barrier cream to the skin after cleaning
  e. Keeping broken skin areas open to air to promote healing

Question 5

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.)
 
  a. Indirect inguinal hernia - An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac
  b. Femoral hernia - A peritoneum sac pushes downward and may descend into the scrotum
  c. Direct inguinal hernia - A peritoneum sac passes through a weak point in the abdominal wall
  d. Ventral hernia - Results from inadequate healing of an incision
  e. Incarcerated hernia - Contents of the hernia sac cannot be reduced back into the abdominal cavity

Question 6

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)
 
  a. Serum potassium of 2.8 mEq/L
  b. Loss of 15 pounds without dieting
  c. Abdominal pain in upper quadrants
  d. Low-pitched bowel sounds
  e. Serum sodium of 121 mEq/L
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Replies
wrote...
6 years ago
The answer to question 1

ANS: A
Right lower quadrant pain, specifically at McBurney's point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.

The answer to question 2

ANS:
720 mg
132 lb = 60 kg.
60 kg  12 mg/kg = 720 mg.

The answer to question 3

ANS: A, D, E
The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the client's nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction.

The answer to question 4

ANS: A, B, D
The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

The answer to question 5

ANS: C, D, E
A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac.

The answer to question 6

ANS: A, C, E
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.
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