Nokea
The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid
- B. Encourage the client to discuss his or her feelings
- C. Administer opioid narcotic medications for pain management
- D. Assist the client out of bed to sit in the chair twice daily
Correct Answer: D
Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.
You may also like to solve these questions
What is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will contact the healthcare provider if feeling unwell.
- B. The client will adhere to the medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will demonstrate understanding of treatments.
Correct Answer: C
Rationale: The primary goal of care for a client diagnosed with sickle cell anemia is to help them live as normal a life as possible. This involves managing symptoms, preventing crises, and promoting overall well-being. While options A, B, and D are important aspects of care, the ultimate goal is to enhance the client's quality of life and support them in leading a fulfilling and active lifestyle despite their condition.
Three major causes of atherosclerosis are:
- A. Hyperthyroidism, underweight, and poor appetite
- B. High blood cholesterol, high blood pressure, and cigarette smoking
- C. Constipation, peptic ulcer disease, and pancreatitis
- D. Kidney failure, edema, and sodium retention
Correct Answer: B
Rationale: Atherosclerosis is primarily caused by high blood cholesterol, high blood pressure, and cigarette smoking. These factors contribute to the buildup of plaque in the arteries. Choices A, C, and D are incorrect. Hyperthyroidism, underweight, and poor appetite do not directly cause atherosclerosis. Similarly, constipation, peptic ulcer disease, pancreatitis, kidney failure, edema, and sodium retention are not among the primary causes of atherosclerosis.
The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb's point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct Answer: A
Rationale: The correct answer is A: Second intercostal space, right sternal border. The aortic valve is best auscultated at the second intercostal space, right sternal border, where the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as they are not the recommended anatomical positions for auscultating the murmur of aortic stenosis.
The client has failed to conceive after many attempts over a three-year time period and asks the nurse, "I have tried everything. What should I do now?" Which statement is the nurse's best response?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The nurse's best response should focus on providing empathetic support and guiding the client to explore further options, such as fertility specialists or treatments. Assessing intravenous fluids for rate and volume is not relevant to the client's concern about infertility. Changing surgical dressing, monitoring medication levels, and tracking meal intake are all unrelated to the client's fertility issues.
The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?
- A. Feed the infant with a newborn nipple while holding him in the recumbent position
- B. Clean the suture site with a cotton-tipped swab soaked in Betadine
- C. Place the infant in the prone position after feeding
- D. Feed the infant with a rubber-tipped syringe and burp frequently
Correct Answer: D
Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not recommended for wound care near the mouth due to its potential toxicity if ingested. Choice C is incorrect because placing the infant in the prone position after feeding can increase the risk of regurgitation and aspiration.