Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient who experienced an upper GI bleed due to gastritis has had the bleeding controlled and the patient's condition is stable. For the next several hours, the nurse caring for this patient should assess for what signs and symptoms of recurrence?
A. Sudden thirst, unrelieved by oral fluid administration
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
B. Tachycardia, hypotension, and tachypnea
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
C. Diaphoresis and sudden onset of abdominal pain
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
D. Tarry, foul-smelling stools
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.
Choice B reason:
This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.
Choice C reason:
Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.
Choice D reason:
Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.
Similar Questions
A client is prescribed lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?
A. During the evening meal
While lansoprazole can be taken with or without food, it is generally recommended to take it before a meal for optimal effectiveness in reducing stomach acid.
B. Thirty minutes before breakfast
This is the correct answer. Taking lansoprazole 30 minutes before breakfast allows it to be most effective in reducing stomach acid production.
C. Thirty minutes after lunch
Taking lansoprazole after lunch may not provide the same level of effectiveness in reducing stomach acid as taking it before a meal.
D. With a bedtime snack.
Taking lansoprazole with a bedtime snack may not be as effective in reducing stomach acid as taking it before a meal. Additionally, it is generally recommended to take it in the morning.
Full Explanation
Choice A reason:
While lansoprazole can be taken with or without food, it is generally recommended to take it before a meal for optimal effectiveness in reducing stomach acid.
Choice B reason:
This is the correct answer. Taking lansoprazole 30 minutes before breakfast allows it to be most effective in reducing stomach acid production.
Choice C reason:
Taking lansoprazole after lunch may not provide the same level of effectiveness in reducing stomach acid as taking it before a meal.
Choice D reason:
Taking lansoprazole with a bedtime snack may not be as effective in reducing stomach acid as taking it before a meal. Additionally, it is generally recommended to take it in the morning.
A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make?
A. "Irregular bowel movements are an indication of poor intestinal health."
This statement does not address the client's use of bisacodyl tablets and instead provides general information about irregular bowel movements.
B. "Decrease your intake of foods high in fiber."
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
C. "Excessive laxative use may cause an electrolyte imbalance."
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially disrupt electrolyte levels.
D. "Chronic use of laxatives can lead to a tear in the rectal mucosa."
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
Full Explanation
Choice A reason:
This statement does not address the client's use of bisacodyl tablets and instead provides general information about irregular bowel movements.
Choice B reason:
Decreasing fiber intake is not a recommended approach, especially for an older adult who may benefit from a balanced diet with adequate fiber.
Choice C reason:
This is the correct answer. Excessive use of laxatives, including bisacodyl, can lead to electrolyte imbalances. Bisacodyl is a stimulant laxative that can cause excessive fluid loss and potentially disrupt electrolyte levels.
Choice D reason:
While chronic use of laxatives can lead to various complications, including potential harm to the rectal mucosa, this choice is not the most appropriate response to the client's current situation.
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
A. Dinner roll
A dinner roll is a generally well-tolerated food option and is unlikely to exacerbate gallbladder inflammation.
B. Tapioca pudding
Tapioca pudding is a soft and easily digestible food, which is suitable for a patient with acute gallbladder inflammation.
C. Mashed potatoes
Mashed potatoes are typically considered a bland and easily digestible food, suitable for a patient with gallbladder inflammation.
D. Fried chicken
Fried chicken is high in fat, which can trigger gallbladder symptoms and exacerbate inflammation. Therefore, it is not an appropriate choice for a patient with acute gallbladder inflammation. The nurse should question this item on the tray.
Full Explanation
Choice A reason:
A dinner roll is a generally well-tolerated food option and is unlikely to exacerbate gallbladder inflammation.
Choice B reason:
Tapioca pudding is a soft and easily digestible food, which is suitable for a patient with acute gallbladder inflammation.
Choice C reason:
Mashed potatoes are typically considered a bland and easily digestible food, suitable for a patient with gallbladder inflammation.
Choice D reason:
Fried chicken is high in fat, which can trigger gallbladder symptoms and exacerbate
inflammation. Therefore, it is not an appropriate choice for a patient with acute gallbladder inflammation. The nurse should question this item on the tray.