Nokea
A nurse is preparing to remove a nasogastric tube from a client. The nurse would instruct the client to do which of the following just before the nurse removes the tube?
- A. To perform Valsalva's maneuver
- B. To take hold and hold a deep breath
- C. To exhale
- D. To inhale and exhale quickly
Correct Answer: B
Rationale: The correct answer is B: To take hold and hold a deep breath. This is because holding a deep breath helps prevent the aspiration of gastric contents when removing the nasogastric tube. By taking a deep breath and holding it, the client creates positive pressure in the lungs, which can help prevent the contents from entering the airway.
Rationale for other choices:
A: Performing Valsalva's maneuver (straining while holding breath) can increase intra-abdominal pressure and potentially push gastric contents upward, increasing the risk of aspiration.
C: Exhaling does not provide the same protection against aspiration as holding a deep breath.
D: Inhaling and exhaling quickly does not create the same protective mechanism as holding a deep breath.
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A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I'm not sure I can avoid alcohol.' The most appropriate response is
- A. Everything will be alright.
- B. I think you should talk more with the doctor about this.
- C. I don't believe that.
- D. I'm not sure that I don't understand. Would you please explain?
Correct Answer: D
Rationale: The correct answer is D because it shows active listening and empathy towards the client's concerns. By asking the client to explain, the nurse can gain a better understanding of the client's perspective and provide tailored support and information. Choice A is incorrect as it dismisses the client's concerns. Choice B is incorrect as it deflects responsibility from the nurse. Choice C is incorrect as it shows disbelief and lacks empathy.
A client had an abdominal perineal resection with a colostomy 4 days ago and is ready for discharge. Which of the following would be an appropriate expected outcome at this point?
- A. The client maintains a high-fiber diet.
- B. The client discusses concerns about his sexual functioning.
- C. The client maintains bedrest.
- D. The client limits fluid intake to 1000 ml/day.
Correct Answer: B
Rationale: The correct answer is B because discussing concerns about sexual functioning is an appropriate expected outcome at this point. After an abdominal perineal resection with a colostomy, it is important for the client to address any concerns related to sexual functioning as it can impact their quality of life.
A: The client maintaining a high-fiber diet is not the most appropriate expected outcome at this point as it may be too soon after surgery to focus solely on dietary adjustments.
C: The client maintaining bedrest is not appropriate as early mobilization is usually encouraged after surgery to prevent complications.
D: Limiting fluid intake to 1000 ml/day is not recommended as adequate hydration is crucial for recovery post-surgery.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
- A. verbalize absence of epigastric pain.
- B. accept the need to inject himself with vitamin B12 for the rest of his life.
- C. understand the need to increase his exercise activity.
- D. eliminate stress from his life.
Correct Answer: A
Rationale: The correct answer is A: verbalize absence of epigastric pain. This outcome is most appropriate as it directly relates to the client's condition of peptic ulcer disease. Verbalizing the absence of epigastric pain indicates that the client's ulcer is healing and symptoms are improving. It is a measurable and specific goal that reflects the client's progress in managing the disease.
Choice B is incorrect as vitamin B12 injections are not typically necessary for peptic ulcer disease. Choice C is incorrect as exercise may not directly impact the ulcer and may even exacerbate symptoms. Choice D is incorrect as eliminating stress completely is unrealistic and may not directly impact the ulcer.
The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?
- A. Encourage regular use of antidiarrheal medications.
- B. Incorporate frequent rest periods into the client's schedule.
- C. Have the client maintain a high-fiber diet.
- D. Wear a gown when providing direct client care.
Correct Answer: B
Rationale: The correct answer is B: Incorporate frequent rest periods into the client's schedule. Rest periods are essential for managing ulcerative colitis exacerbations as they help reduce stress on the digestive system. Antidiarrheal medications (A) may worsen the condition by masking symptoms and delaying appropriate treatment. High-fiber diets (C) can aggravate symptoms in some individuals with ulcerative colitis. Wearing a gown (D) is unrelated to managing ulcerative colitis exacerbations.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.