Nokea
A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be:
- A. Absent
- B. Hyperactive
- C. Normal
- D. Hypoactive
Correct Answer: A
Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.
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A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client's weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct Answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
A healthcare professional is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the healthcare professional include?
- A. When lifting an object, spread your feet apart to provide a wide base of support.
- B. Always lift objects with your back straight and not your legs.
- C. Avoid using any assistive devices.
- D. Bend at the waist to reach objects.
Correct Answer: A
Rationale: The correct instruction to prevent back injuries while lifting is to spread your feet apart to provide a wide base of support. This helps in maintaining stability and reduces the risk of back injury. Choice B is incorrect as lifting objects with your back straight and using your legs is the recommended technique. Choice C is incorrect because assistive devices can actually help prevent back injuries by providing support. Choice D is incorrect as bending at the waist to reach objects can strain the back muscles and increase the risk of injury.
While changing the linen on the client's bed, what should the nurse do?
- A. Hold the linen away from their body and clothing.
- B. Fold the linen neatly before placing it in the laundry.
- C. Wear clean gloves while handling the linen.
- D. Place the linen directly on the floor until the new linen is in place.
Correct Answer: A
Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?
- A. Administer insulin as prescribed.
- B. Administer oral hypoglycemic agents.
- C. Monitor blood glucose levels frequently.
- D. Provide a high-calorie diet.
Correct Answer: A
Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.
When performing cardiac chest compressions, what is a critical concept that the nurse must understand?
- A. Push hard and deep on the chest
- B. Compress the chest at a rapid rate
- C. Perform compressions with minimal interruptions
- D. Use a two-handed technique for compressions
Correct Answer: A
Rationale: The correct answer is to 'Push hard and deep on the chest.' Effective chest compressions during CPR should be forceful and deep enough to adequately circulate blood to vital organs. This helps maintain perfusion and increases the likelihood of a successful outcome. Compressing the chest at a rapid rate (choice B) is important but not as critical as ensuring the compressions are hard and deep. Performing compressions with minimal interruptions (choice C) is also crucial to maintain blood flow. Using a two-handed technique for compressions (choice D) may be helpful but is not as critical as the depth and force of the compressions.