Nokea
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
- A. Place the client's head of bed flat
- B. Apply heat to the client's abdomen
- C. Keep the client on NPO status
- D. Administer a laxative to the client.
Correct Answer: C
Rationale: The correct answer is C: Keep the client on NPO status. This is essential to prevent exacerbation of appendicitis by reducing the risk of bowel obstruction or rupture. Allowing the intestine to rest helps decrease inflammation and pain. Placing the client's head of bed flat (A) can increase intra-abdominal pressure, worsening the condition. Applying heat to the abdomen (B) can mask symptoms and potentially lead to delay in diagnosis. Administering a laxative (D) is contraindicated as it can increase the risk of perforation. In summary, maintaining NPO status is crucial for managing acute appendicitis effectively.
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Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds.
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A, B, F
Rationale: The correct answers are A, B, and F. Increasing oxygen flow rate to 4 L/min helps improve oxygenation. Assessing breath sounds helps monitor respiratory status. Instructing the client to perform diaphragmatic breathing promotes effective breathing. Choices C and D are incorrect because chest percussion, vibration, and placing the client in a supine position are not appropriate interventions for respiratory care. Choice E is incorrect as fluid restriction may worsen respiratory conditions.
A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B12
- C. Vitamin K
- D. Metoclopramide
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Following a total gastrectomy, the client will have reduced intrinsic factor production, leading to vitamin B12 deficiency. Supplementing with Vitamin B12 is crucial to prevent pernicious anemia. Ranitidine (A) is a gastric acid reducer and is not necessary after gastrectomy. Vitamin K (C) is primarily produced in the intestines and is not directly impacted by gastrectomy. Metoclopramide (D) is a prokinetic agent used for gastric motility and is not essential post-gastrectomy.
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time
- B. Complete an incident report if a client vomits after taking a medication
- C. Inform clients about the action of each medication prior to administration
- D. Read medication labels at least two times prior to administration
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is important for promoting patient safety and informed consent. By educating clients about their medications, nurses empower them to be active participants in their own care and help prevent medication errors. Option A is incorrect because preparing medications for multiple clients simultaneously can increase the risk of errors. Option B is incorrect as vomiting after medication administration should be reported to the healthcare provider, not necessarily as an incident report. Option D is incorrect as reading medication labels only once may lead to oversight of important information.
A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?
- A. An induration measuring 10 mm
- B. An induration measuring 5 mm
- C. A reddened area measuring 10 mm
- D. A reddened area measuring 5 mm
Correct Answer: A
Rationale: The correct answer is A: An induration measuring 10 mm. An induration of 10 mm or greater is considered a positive result for a tuberculin skin test in individuals who are at higher risk for tuberculosis. This indicates exposure to the tuberculosis bacteria and an immune response. Choices B, C, and D are incorrect because the presence of redness or a smaller induration size does not meet the criteria for a positive test result. Redness alone does not signify a positive result, and a smaller induration size is not indicative of a positive test. It is important to interpret tuberculin skin tests accurately to guide further testing and treatment decisions.
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.