Nokea
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.
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A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct Answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.