Nokea
A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
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A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
A multidisciplinary team working with the spouse of a home care client who has end-stage liver failure is teaching the spouse about pain management. Which statement by the spouse indicates the need for further teaching?
- A. My husband can use breathing exercises to control pain.
- B. I will help prevent constipation with increased fluids.
- C. If the pain increases, I will report it to the nurse promptly.
- D. The medication causes very deep sleep that my husband needs.
Correct Answer: D
Rationale: In the client with liver disease, the ability to metabolize medication is affected. A decreased level of consciousness is a potential clinical indicator of medication overdose, as well as fluid, electrolyte, and oxygenation deficiencies; thus, the nurse teaches the client's spouse about the differences between sleep related to pain relief and a deteriorating change in neurological status. Options 1, 2, and 3 all indicate an understanding of suitable steps to be taken in pain management.
The nurse managing a client's post-supratentorial craniotomy care should assure that the client is maintained in which position?
- A. Prone
- B. Supine
- C. Semi-Fowler's
- D. Dorsal recumbent
Correct Answer: C
Rationale: Following a supratentorial craniotomy, the client should be maintained in a semi-Fowler's position (head of bed elevated 30 to 45 degrees) to promote venous drainage from the brain, reduce intracranial pressure, and prevent swelling at the surgical site. The prone position could increase pressure on the surgical site and impede breathing. The supine position may increase intracranial pressure due to poor venous drainage. The dorsal recumbent position, while flat with knees flexed, does not provide the elevation needed to reduce intracranial pressure effectively.
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse should include which priority action in the plan?
- A. Monitor intake and output.
- B. Assess the tissue at the surgical site.
- C. Monitor the area for numbness or tingling.
- D. Assess the complete blood cell count results.
Correct Answer: C
Rationale: Arthroscopy provides an endoscopic examination of the joint and is used to diagnose and treat acute and chronic disorders of the joint. The priority nursing action is to monitor the affected area for numbness or tingling, which could indicate neurovascular compromise.
The primary health care provider prescribes 250 mg of amikacin sulfate every 12 hours. How many milliliters (mL) should the nurse prepare to administer one dose? Refer to the figure.
Correct Answer: 5
Rationale: Use the medication calculation formula. Formula: (Desired × mL) / Available = mL per dose. (250 mg × 2 mL) / 100 mg = 5 mL per dose.