Nokea
A client has developed a low inTest inal obstruction. The nurse would anticipate which of the following findings?
- A. Nausea, vomiting, abdominal distention.
- B. Explosive, irritating diarrhea.
- C. Abdominal tenderness with rectal bleeding.
- D. Midepigastric discomfort, tarry stool.
Correct Answer: A
Rationale: there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease
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An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.
An adult woman is admitted to an acute locked psychiatric unit one month prior to an election.
Which of the following responses by the nurse is BEST?
- A. You are not eligible to vote because you are a psychiatric patient.'
- B. I'll make the appropriate arrangements for you to vote.'
- C. You may vote only if you are discharged by Election Day.'
- D. I'll contact the Election Board to see if you are registered to vote.'
Correct Answer: B
Rationale: Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct-patient can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
When describing the correct way for cleansing a wound site, the nurse understands that the wound should be cleaned:
- A. From the top to the bottom two times, with the swab discarded
- B. From the outermost region to the center
- C. With circular motions from the drainage site to the outermost edges
- D. With normal saline followed by an astringent wash
Correct Answer: C
Rationale: Cleaning from the drainage site outward prevents spreading pathogens. Other methods risk contamination or are inappropriate.