Nokea
A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time?
- A. Providing relief from constipation.
- B. Assisting the client with self-care activities.
- C. Maintaining fluid and electrolyte balance.
- D. Minimizing odor formation.
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the highest priority post-ileostomy due to the risk of dehydration from high-output ileostomy effluent. Constipation is not a concern, and self-care or odor control are secondary to physiological stability. CN: Physiological adaptation; CL: Synthesize
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A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?
- A. Decreased cardiac output.
- B. Pleural effusion.
- C. Inadequate peripheral circulation.
- D. Decreased oxygenation of the blood.
Correct Answer: D
Rationale: Cyanosis in pneumonia results from decreased blood oxygenation due to impaired gas exchange in the lungs. Cardiac output, pleural effusion, and peripheral circulation may contribute but are not primary causes.
The nurse is supervising a newly hired nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the newly hired nurse requires follow-up?
- A. irrigates the air vent before medication administration with water.
- B. contacts the pharmacy to obtain available medications in liquid form.
- C. flushes the NGT between medications with water.
- D. administers each medication separately through the NGT.
Correct Answer: A
Rationale: The air vent of an NGT should not be irrigated, as it is for air passage, not medication or fluid administration.
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to:
- A. Act as a diuretic.
- B. Reduce demands on the liver.
- C. Help maintain urine acidity.
- D. Prevent the development of ketosis.
Correct Answer: D
Rationale: A high-carbohydrate, low-protein diet provides energy and prevents ketosis by reducing protein breakdown in acute renal failure.
A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
- A. Treatment of recurrent malignant effusion.
- B. Diagnosis of underlying disease.
- C. Palliation of symptoms.
- D. Relief of acute respiratory distress.
- E. Removal of the cancer cells.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (B), palliates symptoms like dyspnea (C), and relieves acute respiratory distress (D). It does not treat recurrent effusions or remove cancer cells.