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A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
- A. Delirium status.
- B. Vital signs.
- C. Oxygen saturation.
- D. Level of pain.
Correct Answer: D
Rationale: Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.
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Which diet is associated with an increased risk of colorectal cancer?
- A. Low protein, complex carbohydrates
- B. High protein, simple carbohydrates
- C. High fat, refined carbohydrates
- D. Low carbohydrates, complex proteins
Correct Answer: C
Rationale: A diet high in fat and refined carbohydrates increases the risk of colorectal cancer due to prolonged intestinal transit time and exposure to carcinogenic metabolites.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?
- A. Reassess in five minutes.
- B. Check the client’s visual acuity.
- C. Lower the head of the client’s bed.
- D. Contact the physician.
Correct Answer: D
Rationale: implementation, fixed and dilated pupil represents a neurological emergency
The nurse is reviewing medications with a client who is to be scheduled for outpatient rotator cuff repair. Which of the following medications does the nurse anticipate the client will be advised to avoid on the morning of the surgery?
- A. Metoprolol.
- B. Synthroid.
- C. Aspirin.
- D. Prozac.
Correct Answer: C
Rationale: Aspirin (C) is typically avoided before surgery due to its antiplatelet effects, which increase bleeding risk. Metoprolol (A), Synthroid (B), and Prozac (D) are generally continued unless otherwise directed.