A client with a history of PUD is admitted to a medical-surgical unit with pyloric obstruction. The nurse caring for this client knows to monitor for the following symptoms: (SELECT ALL THAT APPLY)

Respiratory acidosis.

Abdominal pain which is relieved by belching.

Sensation of epigastric fullness.

Nausea.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

Pyloric obstruction does not cause respiratory acidosis. Instead, it leads to gastrointestinal symptoms due to obstruction of the stomach's outflow.

Choice B rationale

Abdominal pain relieved by belching is a typical symptom of pyloric obstruction, as it can help release some of the gas and pressure build-up in the stomach.

Choice C rationale

Sensation of epigastric fullness is a common symptom of pyloric obstruction due to the blockage preventing stomach contents from passing into the duodenum.

Choice D rationale

Nausea is a frequent symptom of pyloric obstruction because the stomach's inability to empty properly can lead to discomfort and vomiting. .

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

Withholding food and fluids is essential to prevent complications should surgery be needed.

Choice B rationale

Administering prophylactic IV antibiotics helps prevent infection, which is critical in cases of appendicitis.

Choice C rationale

Applying heat to the abdomen can increase circulation and the risk of rupture in appendicitis.

Choice D rationale

Administering an enema can increase the risk of perforation in appendicitis.

Choice E rationale

Ambulation can exacerbate pain and the risk of rupture in a client with suspected appendicitis.

A. Increase the IV fluid flow rate if the blood pressure is low. B. Listen to the breath sounds in all lung fields. C. Check the abdominal dressing for bleeding. D. Document the amount of output on the I&O sheet.

Correct Answer is D

Explanation

Choice A rationale

Increasing the IV fluid flow rate is a critical task requiring clinical judgment and should not be delegated to an unlicensed nursing assistant. This task involves assessing the patient's hemodynamic status and fluid balance, which requires nursing expertise.

Choice B rationale

Listening to breath sounds in all lung fields is an assessment task that requires nursing knowledge and skills. It involves identifying normal and abnormal breath sounds, which is outside the scope of practice for an unlicensed nursing assistant.

Choice C rationale

Checking the abdominal dressing for bleeding is an assessment and monitoring task. It involves evaluating the wound site for signs of hemorrhage or infection, which requires nursing assessment skills.

Choice D rationale

Documenting the amount of output on the I&O sheet is a task that can be delegated to an unlicensed nursing assistant. This task involves recording measurements, which does not require clinical judgment and is within the assistant's scope of practice.

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A client with a history of PUD is admitted to a medical-surgical unit with pyloric obstruction. The nurse caring for this client knows to monitor for the following symptoms: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B"]

Explanation

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Correct Answer is D

Explanation

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