Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
A. Call the primary provider and report that the client may be obstructed.
This is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
B. Position the client supine and insert an NG tube.
This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
C. Administer a fleet enema as prescribed and remain with the client.
This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
D. Contact the primary provider promptly and report these signs of perforation.
This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nursing 102 Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: This is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
Similar Questions
The nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on?
A. H2-receptor antagonist and two antibiotics
H2-receptor antagonist and two antibiotics is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists are drugs that block the action of histamine on the stomach cells, reducing the production of acid. They are used to treat peptic ulcers, but they are not effective against H. pylori bacteria. The "triple therapy" regimen requires an antibiotic to kill the bacteria, and a proton-pump inhibitor to reduce the acid secretion and promote healing.
B. Two proton-pump inhibitors and an antibiotic
Two proton-pump inhibitors and an antibiotic is not the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, but they are not enough to eradicate H. pylori bacteria. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.
C. H2-receptor antagonist, proton pump inhibitor, and an antibiotic
H2-receptor antagonist, proton pump inhibitor, and an antibiotic is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists and proton-pump inhibitors have similar effects on the stomach acid, but they work in different ways. They are both used to treat peptic ulcers, but they are not necessary to use together. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.
D. Proton-pump inhibitor and two antibiotics
Proton-pump inhibitor and two antibiotics is the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, and they also enhance the effectiveness of the antibiotics. The "triple therapy" regimen requires two antibiotics to kill the H. pylori bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing. The most common antibiotics used are amoxicillin, clarithromycin, and metronidazole.
Full Explanation
Choice A reason: H2-receptor antagonist and two antibiotics is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists are drugs that block the action of histamine on the stomach cells, reducing the production of acid. They are used to treat peptic ulcers, but they are not effective against H. pylori bacteria. The "triple therapy" regimen requires an antibiotic to kill the bacteria, and a proton-pump inhibitor to reduce the acid secretion and promote healing.
Choice B reason: Two proton-pump inhibitors and an antibiotic is not the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, but they are not enough to eradicate H. pylori bacteria. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.
Choice C reason: H2-receptor antagonist, proton pump inhibitor, and an antibiotic is not the correct combination for the "triple therapy" regimen. H2-receptor antagonists and proton-pump inhibitors have similar effects on the stomach acid, but they work in different ways. They are both used to treat peptic ulcers, but they are not necessary to use together. The "triple therapy" regimen requires two antibiotics to kill the bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing.
Choice D reason: Proton-pump inhibitor and two antibiotics is the correct combination for the "triple therapy" regimen. Proton-pump inhibitors are drugs that block the enzyme that produces acid in the stomach, lowering the acidity and allowing the ulcer to heal. They are used to treat peptic ulcers, and they also enhance the effectiveness of the antibiotics. The "triple therapy" regimen requires two antibiotics to kill the H. pylori bacteria, and one proton-pump inhibitor to reduce the acid secretion and promote healing. The most common antibiotics used are amoxicillin, clarithromycin, and metronidazole.
The nurse is providing care for a client with a fluid imbalance. The nurse explains that in the body, areas with high concentration of solutes naturally and passively shift to areas of lower concentration. The nurse is describing which process?
A. Active transport
Active transport is the process of moving molecules across a cell membrane against a concentration gradient, requiring energy.
B. Diffusion
Diffusion is the process of moving molecules from an area of high concentration to an area of low concentration, without using energy.
C. Filtration
Filtration is the process of moving fluid and solutes through a membrane by a pressure gradient.
D. Osmosis
Osmosis is the process of moving water across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration.
Full Explanation
Choice A reason: Active transport is the process of moving molecules across a cell membrane against a concentration gradient, requiring energy.
Choice B reason: Diffusion is the process of moving molecules from an area of high concentration to an area of low concentration, without using energy.
Choice C reason: Filtration is the process of moving fluid and solutes through a membrane by a pressure gradient.
Choice D reason: Osmosis is the process of moving water across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration.
A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the PRIORITY?
A. Constipation
Constipation is not a priority finding for a client with peptic ulcer disease. It may be a side effect of some medications or a result of decreased fluid intake, but it does not indicate a serious complication.
B. Dyspepsia
Dyspepsia is a common symptom of peptic ulcer disease, but it is not a priority finding. It refers to indigestion or discomfort in the upper abdomen, which may be relieved by antacids or other medications.
C. Hematemesis
Hematemesis is a priority finding for a client with peptic ulcer disease. It indicates bleeding from the ulcer, which can lead to shock and anemia. The nurse should monitor the client's vital signs, hemoglobin level, and blood loss, and notify the provider immediately.
D. Epigastric discomfort
Epigastric discomfort is another common symptom of peptic ulcer disease, but it is not a priority finding. It refers to pain or burning in the upper abdomen, which may be worsened by food intake or stress. The nurse should provide comfort measures and educate the client on dietary and lifestyle modifications.
Full Explanation
Choice A reason: Constipation is not a priority finding for a client with peptic ulcer disease. It may be a side effect of some medications or a result of decreased fluid intake, but it does not indicate a serious complication.
Choice B reason: Dyspepsia is a common symptom of peptic ulcer disease, but it is not a priority finding. It refers to indigestion or discomfort in the upper abdomen, which may be relieved by antacids or other medications.
Choice C reason: Hematemesis is a priority finding for a client with peptic ulcer disease. It indicates bleeding from the ulcer, which can lead to shock and anemia. The nurse should monitor the client's vital signs, hemoglobin level, and blood loss, and notify the provider immediately.
Choice D reason: Epigastric discomfort is another common symptom of peptic ulcer disease, but it is not a priority finding. It refers to pain or burning in the upper abdomen, which may be worsened by food intake or stress. The nurse should provide comfort measures and educate the client on dietary and lifestyle modifications.