Nokea
The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
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Which intervention should the nurse implement when administering a potassium supplement?
- A. Determine the client's allergies.
- B. Ask the client about leg cramps.
- C. Monitor the client's blood pressure.
- D. Monitor the client's complete blood count.
Correct Answer: B
Rationale: Asking about leg cramps assesses for hypokalemia symptoms, ensuring the potassium supplement is needed and effective. Allergies, BP, and CBC are less specific.
The nurse writes a problem 'low self-esteem' for a 16-year-old client diagnosed with anorexia. Which client goal should be included in the plan of care?
- A. The client will spend one (1) hour a day with the parents.
- B. The client eats 50% of the meals provided.
- C. Dietary will provide high-protein milk shakes (tid).
- D. The client will verbalize one positive attribute.
Correct Answer: D
Rationale: Verbalizing a positive attribute directly addresses low self-esteem by fostering positive self-perception. Time with parents, eating, and milk shakes are unrelated or nutritional.
The nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement indicates the client understands the discharge instructions?
- A. I should not eat for at least one (1) day following this procedure.
- B. I can lie down whenever I want after a meal. It won't make a difference.
- C. The stomach contents won't bother my esophagus but will make me nauseous.
- D. I should avoid orange juice and eating tomatoes until my esophagus heals.
Correct Answer: D
Rationale: Avoiding acidic foods like orange juice and tomatoes reduces irritation to the esophagus, indicating understanding of dietary modifications for GERD. Not eating for a day is unnecessary, lying down after meals worsens reflux, and nausea is not the primary concern with GERD.
The experienced nurse is instructing the new nurse. The experienced nurse explains that the definitive diagnosis of PUD involves which test?
- A. A urea breath test
- B. Upper GI endoscopy with biopsy
- C. Barium contrast studies
- D. The string test
Correct Answer: B
Rationale: A. A urea breath test only tests for the presence of Helicobacter pylori (H. pylori). B. The gastric mucosa can be visualized with an endoscope. A biopsy is possible to differentiate PUD from gastric cancer and to obtain tissue specimens to identify H. pylori. These are used to make a definitive diagnosis of PUD. C. Barium studies do not provide an opportunity for biopsy and H. pylori testing. D. A urea breath test and a string test only test for the presence of H . pylori.
An adult is being treated for a peptic ulcer. The physician has prescribed cimetidine (Tagamet) for which reason?
- A. It blocks the secretion of gastric hydrochloric acid.
- B. It coats the gastric mucosa with a protective membrane.
- C. It increases the sensitivity of histamine (H2) receptors.
- D. It neutralizes acid in the stomach.
Correct Answer: A
Rationale: Cimetidine, an H2 receptor blocker, reduces gastric acid secretion, aiding peptic ulcer healing.