Nokea
A client has a percutaneous endoscopic gastrostomy tube inserted for tube feedings. Before starting a continuous feeding, the nurse should place the client in which position?
- A. Semi-Fowlers
- B. Supine
- C. Reverse Trendelenburg
- D. High Fowler's
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which of the following nursing interventions should be implemented to manage a client with appendicitis?
- A. Assessing for pain
- B. Encouraging oral intake of clear fluids
- C. Providing discharge teaching
- D. Assessing for symptoms of peritonitis
Correct Answer: D
Rationale: The correct answer is D: Assessing for symptoms of peritonitis. This intervention is crucial in managing a client with appendicitis because it indicates a possible rupture of the inflamed appendix. Symptoms of peritonitis include severe abdominal pain, fever, nausea, vomiting, and abdominal rigidity. Prompt recognition of these symptoms is essential for timely intervention and surgical management. Choices A, B, and C are incorrect because while assessing for pain is important, assessing for symptoms of peritonitis takes precedence due to the critical nature of appendicitis. Encouraging oral intake of clear fluids and providing discharge teaching are not immediate priorities in the management of a client with acute appendicitis.
A client presents to the emergency room, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts him at risk for which of the following?
- A. Metabolic acidosis with hyperkalemia
- B. Metabolic acidosis with hypokalemia
- C. Metabolic alkalosis with hyperkalemia
- D. Metabolic alkalosis with hypokalemia
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client:
- A. Watches the nurse empty the colostomy bag
- B. Looks at the ostomy site
- C. Reads the ostomy product literature
- D. Practices cutting the ostomy appliance
Correct Answer: D
Rationale: The correct answer is D: Practices cutting the ostomy appliance. This choice indicates that the client is actively involved in self-care and adapting to the colostomy. By practicing cutting the ostomy appliance, the client is demonstrating independence and self-management skills, showing significant progress towards overcoming the disturbed body image. Choices A, B, and C do not involve active participation in self-care tasks related to the colostomy, which are essential for the client's adaptation and acceptance.
Which of the following types of diets is implicated in the development of diverticulosis?
- A. Low-fiber diet
- B. High-fiber diet
- C. High-protein diet
- D. Low-carbohydrate diet
Correct Answer: A
Rationale: A low-fiber diet is implicated in the development of diverticulosis because it leads to harder stools and increased pressure in the colon. The lack of fiber results in decreased bulk and slower transit time, predisposing individuals to constipation and the formation of diverticula. High-fiber diets, on the other hand, promote regular bowel movements and help prevent diverticular disease. High-protein and low-carbohydrate diets do not have a direct association with diverticulosis.
Which area of the alimentary canal is the most common location for Crohn's disease?
- A. Ascending colon
- B. Descending colon
- C. Sigmoid colon
- D. Terminal ileum
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.