DETAILED COMPLETE ANSWERS
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The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal
Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note
which assessment finding?
1. Melena
2. Nausea
3. Hernia
4. Hyperthermia - correct answer ✔✔1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry
feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further down
the gastric anatomy.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal
Ulcer. Incorrect.
3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It
is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect.
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect
,The nurse is taking the health history of a patient being treated for Emphysema and Chronic
Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse
expects to note which assessment finding?
1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure - correct answer ✔✔1. Increase in Forced Vital Capacity
(FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A
patient with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest
cavity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for cardiac
failure, this is a potential complication and not an assessment finding. Incorrect.
A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux
Disease. Which of these statements by the patient indicates a need for more teaching?
1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
,2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"
3. "I won't be drinking tea or coffee or eating chocolate any more."
4. "I'm going to start trying to lose some weight." - correct answer ✔✔1. "I'm going to limit my
meals to 2-3 per day to reduce acid secretion."
CORRECT - Large meals increase the volume and pressure in the stomach and delay gastric
emptying. It's recommended instead to eat 4-6 small meals a day.
2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or eating chocolate any more."
Incorrect - This is a correct verbalization of health promotion for GERD.
4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On
assessing lab results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110
beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
1. Start a large-bore IV in the patient's arm
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered - correct answer ✔✔1. Start a large-
bore IV in the patient's arm
, CORRECT - The nurse should suspect that the patient is haemorrhaging and will need need a
fluid replacement therapy, which requires a large bore IV.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not
the priority intervention.
3. Prepare to insert an NG Tube
Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is
not the first and priority intervention.
4. Administer intramuscular morphine sulphate as ordered
Incorrect - While this is an important intervention to manage pain, it is not the priority
intervention.
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a
platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and
should be reported to the physician immediately?
1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L - correct answer ✔✔1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab
result.
2. Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.