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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Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The nurse is planning the care of a client who has had an abdominal-perineal resection for cancer of the colon. Which interventions should the nurse implement?
- A. Provide meticulous skin care to stoma.
- B. Assess the flank incision.
- C. Maintain the indwelling catheter.
- D. Irrigate the (JP) drains every shift.
- E. Position the client semirecumbent.
Correct Answer: A,C,E
Rationale: Stoma skin care prevents irritation, an indwelling catheter is maintained post-surgery to monitor output, and a semirecumbent position aids breathing and comfort. Flank incisions are not typical, and JP drains are not irrigated.
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 assessing a client who may have a hiatal hernia. What symptom is the client most likely to report?
- A. Projectile vomiting
- B. Crampy lower abdominal pain
- C. Burning substernal pain
- D. Bloody diarrhea
Correct Answer: C
Rationale: Burning substernal pain, often mistaken for heartburn, is a hallmark symptom of hiatal hernia due to acid reflux.