Question

Which assessment findings will the nurse anticipate in the client with cholelithiasis?

Answer 1

Correct Answers:

Right upper quadrant abdominal pain, nausea/vomiting

Rationale :

🔹 Biliary colic occurs when gallstones obstruct the cystic duct, producing severe right upper quadrant pain often radiating to the right shoulder.

🔹 Nausea and vomiting are common due to visceral pain and autonomic nervous system stimulation.

🔹 The pain is often triggered after fatty meals because cholecystokinin stimulates gallbladder contraction.

🔹 Inflammation of the gallbladder (cholecystitis) may accompany cholelithiasis, worsening symptoms.

🔹 Murphy’s sign may be present—tenderness on palpation with inspiration over the gallbladder area

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Answer 2

Correct Answers:

Out of bed three times daily & ad lib.

Rationale :

🔹 Spinal fusion patients require strict mobility precautions to prevent hardware displacement.

🔹 Early ambulation without surgeon clearance risks spinal instability and neurological damage.

🔹 Post-op orders usually limit mobility to logrolling and brief position changes only.

🔹 Nurses must question unsafe orders that conflict with surgical recovery protocols.

🔹 Protecting the surgical site during early healing is a priority to prevent complications.

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Answer 3

Correct Answers:

Tingling in the toes of fractured extremity and decreased sensation.

Rationale :

🔹 These findings indicate neurovascular compromise associated with compartment syndrome.

🔹 Tingling and sensory loss occur from nerve ischemia due to increased compartment pressure.

🔹 If unrelieved, this can progress to irreversible nerve and muscle damage.

🔹 Prompt recognition and notification of the provider are critical for limb salvage.

🔹 Pain out of proportion to injury and unrelieved by opioids is often present with sensory changes

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Answer 4

Correct Answers:

Cobalamin (B12) Injections.

Rationale :

🔹 Pernicious anemia results from intrinsic factor deficiency leading to impaired B12 absorption.

🔹 Oral B12 is ineffective because the GI tract cannot absorb it without intrinsic factor.

🔹 Lifelong injections are required to prevent neurological damage and anemia recurrence.

🔹 B12 is vital for DNA synthesis and red blood cell maturation.

🔹 Without treatment, patients risk irreversible peripheral neuropathy.

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Answer 5

Correct Answers:

"I will increase my intake of meat and beans.”
"I will take a Vitamin C supplement to increase iron absorption."
“This anemia may occur more during pregnancy of menstruation.""

Rationale :

🩸 Increase meat and beans – Meat, beans, and green leafy vegetables are iron-rich foods essential for replenishing iron stores.

🩸Vitamin C supplementation – Vitamin C enhances non-heme iron absorption in the intestine.

🩸 Pregnancy/menstruation risk – These increase iron requirements and can predispose to deficiency.

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Answer 6

Correct Answers:

Notify the surgeon that the informed consent process is not complete.

Rationale :

🔹 Informed consent must include understanding of procedure, risks, and benefits.

🔹 If the patient expresses lack of understanding, the surgeon must re-explain before proceeding.

🔹 Nurses serve as witnesses, not as the primary educators for surgical details.

🔹 Proceeding without complete consent violates patient autonomy and legal standards.

🔹 Delaying surgery until consent is valid protects patient rights and hospital liability.

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Answer 7

Correct Answers:

Aspiration

Rationale :

🔹 Under general anesthesia, loss of protective airway reflexes increases risk of gastric content aspiration.

🔹 Aspiration can cause chemical pneumonitis or pneumonia postoperatively.

🔹 Preoperative fasting reduces risk but does not eliminate it.

🔹 Airway management with endotracheal intubation is critical during anesthesia.

🔹 Aspiration is a serious, preventable complication requiring vigilant monitoring

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Answer 8

Correct Answers:

Client is taking Prednisone and recovering from a urinary tract infection.

Rationale :

🔹 Infections increase metabolic demands and can trigger DKA even in compliant diabetics.

🔹 Prednisone elevates blood glucose by promoting gluconeogenesis and insulin resistance.

🔹 Steroids combined with infection can overwhelm glycemic control.

🔹 DKA occurs due to absolute or relative insulin deficiency with hyperglycemia and ketosis.

🔹 Identifying precipitating factors is essential to prevent recurrence

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Answer 9

Correct Answers:

3 units of his prescribed rapid acting insulin.

Rationale :

🔹 Insulin lispro is rapid-acting, used for mealtime glucose control.

🔹 Dose is calculated: 150 g ÷ 50 g/unit = 3 units.

🔹 Rapid-acting insulin should be given with or just before meals to match carbohydrate intake.

🔹 Prevents postprandial hyperglycemia by mimicking normal insulin response.

🔹 Timing and accurate carb counting are crucial for safety in type 1 diabetes.

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Answer 10

Correct Answers:

Opioid tolerance

Rationale :

🔹 Tolerance develops when higher doses are required to achieve the same effect.

🔹 It occurs due to neuroadaptation of opioid receptors over time.

🔹 This is distinct from dependence or addiction—it is a physiological adaptation.

🔹 Pain management plans often require dose adjustments in chronic use.

🔹 Recognizing tolerance helps prevent undertreatment of pain.

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QLexNursing

1 :
Which assessment findings will the nurse anticipate in the client with cholelithiasis?

2 :
The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

3 :
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

4 :
The nurse will plan to teach a patient who has pernicious anemia about the need for:

5 :
The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency?( SELECT ALL THAT APPLY)

6 :
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

7 :
What is one airway complication that can occur during surgery when the patient is receiving general anesthesia care?

8 :
A client is admitted with Diabetic Ketoacidosis (DKA). The client asks the nurse "Why did this happen? I have been taking my insulin as prescribed and following my diet carefully" The nurse reviews the client's chart and realizes that this emergency may be related to which common causes of DKA?

QLexNursing

1 : Which assessment findings will the nurse anticipate in the client with cholelithiasis?

2 : The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

3 : The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

4 : The nurse will plan to teach a patient who has pernicious anemia about the need for:

5 : The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency?( SELECT ALL THAT APPLY)

6 : The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

7 : What is one airway complication that can occur during surgery when the patient is receiving general anesthesia care?

8 : A client is admitted with Diabetic Ketoacidosis (DKA). The client asks the nurse "Why did this happen? I have been taking my insulin as prescribed and following my diet carefully" The nurse reviews the client's chart and realizes that this emergency may be related to which common causes of DKA?

1 :
Which assessment findings will the nurse anticipate in the client with cholelithiasis?

2 :
The nurse is caring for an adolescent diagnosed with scoliosis who just arrived to the floor from the recovery room after a Spinal fusion surgery. The nurse should question which physician order?

3 :
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment finding indicates possible compartment syndrome?

4 :
The nurse will plan to teach a patient who has pernicious anemia about the need for:

5 :
The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency?( SELECT ALL THAT APPLY)

6 :
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?

7 :
What is one airway complication that can occur during surgery when the patient is receiving general anesthesia care?

8 :
A client is admitted with Diabetic Ketoacidosis (DKA). The client asks the nurse "Why did this happen? I have been taking my insulin as prescribed and following my diet carefully" The nurse reviews the client's chart and realizes that this emergency may be related to which common causes of DKA?