Category: Uncategorized

A 58-year-old patient with long-standing alcohol-related cirrhosis is admitted with increasing abdominal distention and confusion. Assessment findings include ascites, jaundice, and asterixis. Vital signs: BP 90/58 mmHg, HR 118 bpm. Laboratory results: serum albumin 2.1 g/dL, ammonia 75 µg/dL (normal 15 to 45 µg/dL), sodium 128 mEq/L, INR 2.8. The provider prescribes: Lactulose 30 mL PO TID Spironolactone 100 mg daily Propranolol 20 mg BID Large-volume paracentesis Which nursing action is highest priority prior to implementing these orders?  

A 52-year-old patient with chronic pancreatitis reports persistent epigastric pain rated 5/10 despite taking prescribed oxycodone every 4 hours as directed. The patient also reports greasy, foul-smelling stools and a 10-pound weight loss over the past month and states, “The pain is worst after I eat.” Which action by the nurse is most appropriate?  

A patient with Crohn’s disease has a serum magnesium of 1.1 mEq/L. Which assessment finding may the nurse anticipate?  

A patient with a history of Chron’s disease has undergone a terminal ileum resection. The provider prescribes cyanocobalamin. The patient asks the nurse, “Why can’t I just take a B12 vitamin by mouth like I used to?” Which response by the nurse best explains the rationale?  

A nurse is caring for a 10-year-old child admitted with abdominal pain of unclear origin. Over the past 6 hours, the child reports that the pain initially began around the umbilicus and has now localized to the right lower quadrant. The child is guarding the abdomen and has a temperature of 38.3°C. Which nursing action is the priority?

A nurse is caring for a patient admitted with acute cholecystitis. On assessment the nurse notes a positive Murphy’s sign, RUQ tenderness, temperature of 38.2°C, and nausea after eating. Which nursing interventions does the nurse include in the plan of care? (Select all that apply)  

A patient with esophageal varices has a Sengstaken-Blakemore tube in place for active bleeding. The provider orders insertion of an additional nasogastric tube. The patient’s family asks, “He already has a tube — why does he need another one?” Which response by the nurse best explains the rationale?  

A nurse is caring for a patient admitted with acute cholecystitis. On the second day of admission, the patient reports their “urine looks like coca cola” and their stool appears “pale.” Laboratory results show a bilirubin of 4.2 mg/dL (reference range 0.3–1.2 mg/dL). Which interpretation by the nurse is most accurate?  

A client is receiving a continuous IV infusion of heparin. The IV pump is currently set to infuse at 18 mL/hr. The available solution is 20,000 units of heparin in 250 mL of D5W. How many units per hour is the client receiving?  Round to the nearest whole number.

A patient newly diagnosed with irritable bowel syndrome tells the nurse, “My doctor keeps asking me about my stress levels. I’m not making this up — my pain and diarrhea are real. Why does stress even matter if this is a bowel problem?” Which response by the nurse best explains the relationship?