A client is admitted to the nursing unit with a diagnosis of gastric ulcer. Which assessment finding by the nurse supports the client's diagnosis of gastric ulcer?
Elevated serum potassium levels
Increased white blood cell count
Mid epigastric pain that worsens with eating
Epigastric pain that worsens with eating
The Correct Answer is D
A. Elevated serum potassium levels are not a specific finding related to gastric ulcers. They may be seen with other conditions such as kidney dysfunction or the use of certain medications (e.g., diuretics).
B. An increased white blood cell count is often associated with infection or inflammation but is not specific to gastric ulcers.
C. Mid epigastric pain that worsens with eating is more characteristic of duodenal ulcers, not gastric ulcers.
D. Epigastric pain that worsens with eating is a hallmark symptom of a gastric ulcer. This pain is typically aggravated by food intake due to the increased acid production in the stomach during digestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering anticoagulant medications is contraindicated in patients with bleeding esophageal varices. Anticoagulants could worsen bleeding and complicate the condition further. The goal in managing esophageal varices is to control the bleeding, not to increase the risk of bleeding.
B. Monitoring vital signs frequently is critical in patients with bleeding esophageal varices, as they are at risk for hypovolemic shock. Vital signs should be monitored closely to assess for signs of bleeding, hemodynamic instability, and response to interventions. Typically, more frequent monitoring (every 15 minutes initially, then every hour) is indicated, not just every 4 hours.
C. A high-fiber diet is not appropriate for patients with bleeding esophageal varices. This can increase intra-abdominal pressure and may worsen bleeding. The diet should be tailored to the patient's needs, typically involving low-residue or soft foods depending on their condition.
D. Assisting with the insertion and removal of the balloon tamponade device should be done by a skilled provider, not the nurse. The nurse's role involves monitoring for complications, ensuring proper positioning, and assessing the patient's response to treatment.
Correct Answer is A
Explanation
A. The IV tubing for TPN should be changed every 24 hours to prevent infection, as TPN is a high-risk solution for bacterial growth due to its high glucose content. Regular changes help reduce the risk of contamination and complications such as bloodstream infections.
B. The IV site dressing should be changed at least every 48 to 72 hours (or per institutional policy) to maintain aseptic technique and minimize infection risk. Changing the dressing every 4 days may exceed this timeframe and increase the risk of infection.
C. Weighing the client is important to monitor fluid balance, but daily weighing is more typical than every other day for clients receiving TPN. This helps to assess nutritional status and detect potential fluid overload or deficit.
D. Blood glucose levels should be monitored more frequently, typically every 6 hours, because TPN can cause significant fluctuations in blood glucose. Checking every 12 hours would not be adequate for early detection of hyperglycemia or hypoglycemia.
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