Nokea
A client comes to the health clinic 3 years after undergoing a resection of the terminal ileum and tells the nurse that he has weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?
- A. I have been drinking plenty of fluids.'
- B. I have been gargling with warm salt water for my sore tongue.'
- C. I have three to four loose stools per day.'
- D. I take a vitamin B12 tablet every day.'
Correct Answer: D
Rationale: Resection of the terminal ileum impairs vitamin B12 absorption, as the ileum is the primary site for B12 uptake. The client's symptoms (weakness, shortness of breath, sore tongue) suggest B12 deficiency, likely due to inadequate absorption of oral B12 supplements. The statement about taking a B12 tablet daily indicates a need for intervention, as the client may require intramuscular B12 injections. The other statements are appropriate or expected (loose stools are common post-resection).
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A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
The unliscensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should:
- A. Maintain complete bed rest.
- B. Check the urine output.
- C. Ask the UAP to change the linens.
- D. Administer a beta blocker
Correct Answer: B
Rationale: A client with pneumonia experiencing diaphoresis is at risk for dehydration. The fluid status, intake, and output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume defi cit may also increase the heart rate. A beta blocker is not indicated since the underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and fl uid volume. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety
A client with acute renal failure is at risk for:
- A. Infection.
- B. Hypoglycemia.
- C. Hypernatremia.
- D. Bone fractures.
Correct Answer: A
Rationale: Infection risk is high due to impaired immune response and dialysis access.
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
The nurse is teaching a client how to manage a nosebleed. Which of the following instructions would be appropriate to give the client?
- A. Tilt your head backward and pinch your nose.
- B. Lie down flat and place an ice compress over the bridge of the nose.
- C. Blow your nose gently with your neck
- D. Sit down, lean forward, and pinch the soft portion of your nose.
Correct Answer: D
Rationale: Sitting and leaning forward while pinching the soft portion of the nose compresses the bleeding site and prevents blood from flowing down the throat. Tilting backward can cause swallowing of blood. Lying flat is not recommended. Blowing the nose can worsen bleeding.