The nurse is caring for a patient with esophageal varices. Which symptom should alert the nurse to possible bleeding?
a. Asterixis
b. Dark amber urine
c. Hard formed stool
d. Blood-streaked emesis
ANS: D
Blood from varices may streak emesis or may be more frank. B. C. Constipation and dark urine may accompany liver disease but are not signs of bleeding. A. Asterixis is a sign of encephalopathy.
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A client has a metastatic bone tumor. What action by the nurse takes priority?
a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Handle the affected extremity with caution. d. Place the client on protective precautions.
An informed consent was to be obtained from the patient for his scheduled open cholecystectomy. Which circumstance could prevent the patient from signing his informed consent?
a. Pain radiating to the scapula b. An injection of Demerol, 75 mg IM, 1 hour ago c. The presence of jaundice and scleral icterus d. His concern over his insurance company not covering the procedure
A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations
What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula.
A person has continuous enteral nutrition. The nurse asks you to add ice chips around the container. This is done:
a. So formula is given chilled b. To prevent the growth of microbes c. To prevent aspiration d. To prevent regurgitation