The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?

Promptly assess the client for a potential perforation

Tell the assistant to change thermometers and retake the temperature

Plan to give the client acetaminophen the lower temperature

Ask the assistant to bathe the client with tap water

Answer and Explanation

The Correct Answer is A

A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. A hiatal hernia can increase the risk of gastroesophageal reflux disease (GERD) because the hernia can cause the lower esophageal sphincter to malfunction, leading to the backflow of stomach acid into the esophagus. This increases the risk of reflux symptoms, such as heartburn and regurgitation.
B. There is no direct link between a hiatal hernia and an increased risk for stomach cancer. While long-term GERD can contribute to other esophageal issues, such as Barrett’s esophagus, it does not directly cause stomach cancer.
C. A hiatal hernia does not increase the risk of intestinal cancer. Its primary association is with GERD and related complications.
D. A hiatal hernia is not associated with an increased risk for lung disease. However, severe GERD symptoms can cause respiratory issues such as aspiration pneumonia, but this is not the same as directly increasing the risk of lung disease.

A. Administer a broad-spectrum antibiotic to prevent infection. B. Notify the healthcare provider immediately and wait for further instructions. C. Obtain a culture specimen of the drainage, apply a sterile dressing over the site, and monitor for any signs of infection. D. Remove the sutures immediately to prevent further drainage.

Correct Answer is C

Explanation

A. Administering a broad-spectrum antibiotic is not the first action in this case. The first priority is to assess the situation and obtain a culture of the drainage to identify any infection before initiating antibiotics.
B. While notifying the healthcare provider is important, it is more important to take an initial action by obtaining a culture specimen. Waiting without taking action could delay appropriate care.
C. The best first action is to obtain a culture of the drainage to identify any potential infection, apply a sterile dressing, and continue to monitor the site for further signs of infection. Culturing the drainage helps guide the appropriate treatment.
D. Removing the sutures is not the appropriate action. The sutures should not be removed unless there is clear indication, as this could disrupt the integrity of the catheter placement.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the primary care office who has a recent diagnosis of a hiatal hernia. Which of the following new information will be beneficial for the nurse to relay to the client?

Correct Answer is A

Explanation

The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse noticed the presence of a yellow drainage from around the sutures that are anchoring the catheter. Which actions should the nurse take first?

Correct Answer is C

Explanation

The nurse is completing discharge teaching with a patient following an ileostomy. Which statement by the patient indicates the need for more teaching concerning the ileostomy?

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

The nurse is caring for a client diagnosed with pneumonia. Which interventions should the nurse include in the plan of care? (Select All that Apply.)

Which of the following statements about strictureplasty is correct?

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A client diagnosed with type II diabetes is prescribed prednisone for an acute exacerbation of inflammatory bowel disease. Which management strategy should the nurse discuss with the client?

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

A nurse is preparing to administer atenolol 25 mg PO every 12 hr. The amount available is atenolol 50 mg/tab. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)