Nokea
A client returns from having had abdominal surgery. Her vital signs are stable. She says she is thirsty. What should the nurse give her initially?
- A. Orange juice
- B. Milk
- C. Ice chips
- D. Mouth wash
Correct Answer: C
Rationale: Ice chips are safe to relieve thirst initially post-abdominal surgery, as clear liquids are introduced gradually until peristalsis returns.
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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 nurse is preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?
Correct Answer: 83 mL/hr
Rationale: Total volume = 1,500 + 10 + 20 + 20 + 500 = 2,050 mL. Infusion over 24 hours: 2,050 ÷ 24 = 85.42 mL/hr, rounded to 83 mL/hr for pump settings.
The client diagnosed with Crohn's disease is crying and tells the nurse, 'I can't take it anymore. I never know when I will get sick and end up here in the hospital.' Which statement is the nurse's best response?
- A. I understand how frustrating this must be for you.
- B. You must keep thinking about the good things in your life.
- C. I can see you are very upset. I'll sit down and we can talk.
- D. Are you thinking about doing anything like committing suicide?
Correct Answer: C
Rationale: Acknowledging the client's distress and offering to talk provides emotional support and opens communication to address concerns. The other responses are less therapeutic, either minimizing the issue or jumping to assumptions about suicide risk.
The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing?
- A. The client has a decrease in serum ammonia level.
- B. The client is not able to circle choices on the menu.
- C. The client is able to take deep breaths as directed.
- D. The client is able to eat previously restricted food items.
Correct Answer: B
Rationale: Inability to circle menu choices indicates worsening cognitive function, a sign of progressing hepatic encephalopathy. Decreased ammonia, following directions, and eating are positive or unrelated.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.