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A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.
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The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session?
- A. Discuss the importance of drinking 1,000 mL of water daily.
- B. Instruct the client to exercise at least three (3) times a week.
- C. Teach the client about eating a low-residue diet.
- D. Explain the need to have daily bowel movements.
Correct Answer: B
Rationale: Regular exercise promotes bowel motility, reducing the risk of diverticulitis in diverticulosis. A high-fiber diet (not low-residue) is recommended, 1,000 mL of water is insufficient, and daily bowel movements are not mandatory.
Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
- A. Complaints of sudden, sharp, substernal pain.
- B. Rigid, boardlike abdomen with rebound tenderness.
- C. Frequent, clay-colored, liquid stool.
- D. Complaints of vague abdominal pain in the right upper quadrant.
Correct Answer: B
Rationale: A rigid, boardlike abdomen with rebound tenderness indicates peritonitis, a common complication of ulcer perforation due to leakage of gastric contents into the peritoneal cavity. Substernal pain, clay-colored stools, and vague pain are less specific.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.
A client returns from having had abdominal surgery. Her vital signs are stable. She says she is thirsty. What should the nurse give her initially?
- A. Orange juice
- B. Milk
- C. Ice chips
- D. Mouth wash
Correct Answer: C
Rationale: Ice chips are safe to relieve thirst initially post-abdominal surgery, as clear liquids are introduced gradually until peristalsis returns.
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Check the abdominal dressings for bleeding.
- B. Increase the IV fluid if the blood pressure is low.
- C. Ambulate the client to the bathroom.
- D. Auscultate the breath sounds in all lobes.
Correct Answer: C
Rationale: Ambulating the client is within the UAP’s scope, promoting recovery. Checking dressings, adjusting IV fluids, and auscultating breath sounds require RN assessment skills.