Nokea
A client has received a dose of an as-needed medication loperamide. The nurse evaluates the client after administration to determine if the client has relief of which sign/symptom?
- A. Diarrhea
- B. Tarry stools
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Loperamide is an antidiarrheal agent, and it is commonly administered after loose stools. It is used for the management of acute diarrhea and also for chronic diarrhea, such as with inflammatory bowel disease. It can also be used to reduce the volume of drainage from an ileostomy. It is not intended to treat any of the other options.
You may also like to solve these questions
The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?
- A. Elevate the head of the bed.
- B. Provide oxygen during stressful periods.
- C. Limit the time that the infant is allowed to bottle-feed.
- D. Wake the infant for feedings to ensure adequate nutrition.
Correct Answer: D
Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.
The nurse reviews the nursing care plan of a hospitalized preschool child who is immobilized as a result of skeletal traction. The nurse notes concerns related to the child's development because of immobilization and hospitalization. Which evaluative statement indicates a positive outcome for the child?
- A. The fracture heals without complications.
- B. The caregivers verbalize safe and effective home care.
- C. The child maintains normal joint and muscle integrity.
- D. The child displays age-appropriate developmental behaviors.
Correct Answer: D
Rationale: Regression and inappropriate developmental behaviors may be displayed in response to immobilization and hospitalization. With individualized care planning, a positive outcome of age-appropriate behavior can be achieved. The remaining options are appropriate evaluative statements for an immobilized child, but they do not directly address the child's development.
The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
A woman in labor is receiving oxytocin by intravenous infusion. The nurse monitors the client, knowing that which finding indicates an adequate contraction pattern?
- A. One contraction per minute, with resultant cervical dilation
- B. Four contractions every 5 minutes, with resultant cervical dilation
- C. One contraction every 10 minutes, without resultant cervical dilation
- D. Three to 5 contractions in a 10-minute period, with resultant cervical dilation
Correct Answer: D
Rationale: The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by 3 to 5 contractions in a 10-minute period, with resultant cervical dilation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.
The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?
- A. The suction gauge reads low intermittent suction.
- B. The client indicates that pain is a 3 on a scale of 1 to 10.
- C. The distal end of the NG tube is pinned to the client's gown.
- D. The client denies nausea and has 250 mL of fluid in the suction collection container.
Correct Answer: D
Rationale: An NG tube connected to suction is used postoperatively to decompress and rest the bowel. The gastrointestinal tract lacks peristaltic activity as a result of manipulation during surgery. The client should not experience symptoms of ileus (nausea and vomiting) if the tube is functioning properly. Although the nurse makes pertinent observations of the tube to ensure that it is secure and properly connected to suction, the client is assessed for the effect. A pain indicator of 3 is an expected finding in a postoperative client.