Nokea
A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract?
- A. Compression.
- B. Lavage.
- C. Decompression.
- D. Gavage.
Correct Answer: C
Rationale: An NG tube is used for decompression to remove air and fluid from the gastrointestinal tract post-surgery.
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The maternity nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. Which information should the nurse provide to the client about the purpose of estrogen?
- A. It maintains the uterine lining for implantation.
- B. It stimulates metabolism of glucose and converts the glucose to fat.
- C. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
- D. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
Correct Answer: D
Rationale: Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
A client with a history of chronic kidney disease is admitted with edema. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypermagnesemia.
- E. Hypophosphatemia.
Correct Answer: A, B, C, D
Rationale: Chronic kidney disease can cause hyperkalemia, hyponatremia, hypocalcemia, and hypermagnesemia due to impaired excretion and filtration.
A client who has had a laparoscopic cholecystectomy receives discharge instructions from the nurse. Which statement indicates that the client has understood the instructions?
- A. I need to maintain a low-fat diet for the next 6 months
- B. I can remove the dressing from my incision tomorrow and take a shower
- C. I can anticipate some nausea for several days after surgery
- D. I can return to work in 4 to 6 weeks
Correct Answer: B
Rationale: Removing the dressing and showering the day after a laparoscopic cholecystectomy is standard, as incisions are small. A low-fat diet may be advised but not for a fixed 6 months, nausea is not expected, and return to work is typically sooner.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
Which federal law is most closely associated with the highly restrictive 'need to know'?
- A. The Patient Self Determination Act
- B. The Mental Health Parity Act
- C. The Health Insurance Portability and Accountability Act
- D. The Americans with Disabilities Act of 1990
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.