following a cva the nurse assess that a client developed dysphagia hypoactive bowel sounds and a firm distended abdomen which prescription for the cli

ATI LPN

ATI Adult Medical Surgical

1. Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

A. Continuous tube feeding at 65 ml/hr via gastrostomy.
B. Total parenteral nutrition to be infused at 125 ml/hour.
C. Nasogastric tube connected to low intermittent suction.
D. Metoclopramide (Reglan) intermittent piggyback.

Correct answer: A

Rationale: In a client with dysphagia and gastrointestinal symptoms such as hypoactive bowel sounds and a firm, distended abdomen, continuous tube feeding might exacerbate the symptoms. This can lead to complications and should be questioned by the nurse.

2. Which regimen is most effective for treating H. pylori infection?

A. Metronidazole, bismuth subsalicylate, amoxicillin for 14 days
B. Clarithromycin and omeprazole for 14 days
C. Metronidazole, lansoprazole, and clarithromycin for 14 days
D. Metronidazole, clarithromycin, and omeprazole for 7 days

Correct answer: C

Rationale: Regimen C, which consists of metronidazole, lansoprazole, and clarithromycin for 14 days, is recommended by the FDA as an effective treatment for H. pylori infection. This regimen has been shown to have a high eradication rate and is a standard recommendation in clinical practice guidelines for the management of H. pylori-related conditions.

3. A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?

A. Notify the healthcare provider of the assessment findings.
B. Determine if the client received anesthesia during delivery.
C. Assign a licensed nurse to reassess the client's vital signs.
D. Obtain a STAT hemoglobin and hematocrit.

Correct answer: B

Rationale: The correct action to implement first is to determine if the client received anesthesia during delivery. Anesthesia can be a potential cause of postpartum headaches. This information is crucial in assessing and managing the client's condition effectively before considering other interventions. It helps in identifying possible contributing factors to the client's complaint of a severe headache and guides the healthcare team in providing appropriate care and treatment.

4. While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?

A. Continue the magnesium sulfate infusion as prescribed.
B. Decrease the magnesium sulfate infusion by one-half.
C. Stop the magnesium sulfate infusion immediately.
D. Administer calcium gluconate immediately.

Correct answer: C

Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.

5. Which of the following statements about Helicobacter pylori (H. pylori) is false?

A. H. pylori does not invade the gastric or duodenal epithelium
B. H. pylori stimulates gastric acid secretion
C. Eradication of H. pylori prevents adenocarcinoma of the stomach
D. H. pylori produces a urease that splits urea into ammonia and CO2

Correct answer: C

Rationale: H. pylori is known to reside in the mucus layer of the stomach and does not invade the epithelium. It produces urease that splits urea into ammonia and CO2. This action helps in neutralizing the acidic environment and allows H. pylori to survive. Additionally, urease activity can be detected in diagnostic tests for H. pylori. The stimulation of gastric acid secretion and disruption of the protective mucus layer are mechanisms by which H. pylori promotes injury. While eradicating H. pylori infection has been associated with a decreased risk of developing gastric cancer, it does not prevent adenocarcinoma of the stomach entirely.