Nokea
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
You may also like to solve these questions
The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Check the abdominal dressings for bleeding.
- B. Increase the IV fluid if the blood pressure is low.
- C. Ambulate the client to the bathroom.
- D. Auscultate the breath sounds in all lobes.
Correct Answer: C
Rationale: Ambulating the client is within the UAP’s scope, promoting recovery. Checking dressings, adjusting IV fluids, and auscultating breath sounds require RN assessment skills.
The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.
During a health promotion seminar for senior citizens, a participant asks the nurse to discuss symptoms of gastric cancer. Which statement should be the basis for the nurse’s response?
- A. Cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients.
- B. Pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists.
- C. Unexplained weight gain and increased body mass index (BMI) are early symptoms of gastric cancer.
- D. Anemia is uncommon in gastric cancer, but if it occurs, it is likely due to the effects of aging.
Correct Answer: A
Rationale: A. Eighty percent of clients with early gastric cancer do not have symptoms. B. Pain caused by gastric cancer can be alleviated by OTC histamine receptor antagonists. C. Weight loss and anemia are common symptoms, not weight gain and increased BMI. D. Anemia occurs from malabsorption and nutritional deficiencies, not the effects of aging.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
- A. Notify the surgeon immediately.
- B. Instruct the client to splint the incision.
- C. Assess the abdominal wound incision.
- D. Administer pain medication intravenously.
Correct Answer: C
Rationale: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.
The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase?
- A. Clay-colored stools and jaundice.
- B. Normal appetite and pruritus.
- C. Being afebrile and left upper quadrant pain.
- D. Complaints of fatigue and diarrhea.
Correct Answer: D
Rationale: The preicteric phase of hepatitis involves nonspecific symptoms like fatigue and diarrhea before jaundice appears. Clay-colored stools, jaundice, and pruritus occur in the icteric phase.