Nokea
A client who had a cholecystectomy has a biliary drainage tube in place. Which of the following colors of the drainage is expected?
- A. Pinkish red.
- B. Dark yellow-orange.
- C. Clear.
- D. Green.
Correct Answer: D
Rationale: Biliary drainage after cholecystectomy is typically green due to bile, which is produced by the liver and stored in the gallbladder.
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A client who has undergone abdominal or pelvic surgery. In order to prevent deep vein thrombosis (DVT), the nurse should:
- A. Restrict fluids
- B. Encourage deep breathing
- C. Assist the client to remain sedentary
- D. Use pneumatic compression stockings
Correct Answer: D
Rationale: Pneumatic compression stockings prevent DVT post-surgery by promoting venous return and reducing stasis. Restricting fluids increases viscosity, deep breathing aids respiratory function, and remaining sedentary increases DVT risk.
Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it:
- A. Decreases blood pressure.
- B. Increases tubular reabsorption of water.
- C. Increases release of insulin from the pancreas.
- D. Decreases glucose production within the liver.
Correct Answer: B
Rationale: Vasopressin increases water reabsorption in the kidneys, reducing urine output in diabetes insipidus.
The nurse is reviewing laboratory reports for a client who is taking allopurinol (Zyloprim). Which of the following indicate that the drug has had a therapeutic effect?
- A. Decreased urine alkaline phosphatase level.
- B. Increased urine calcium excretion.
- C. Increased serum calcium level.
- D. Decreased serum uric acid level.
Correct Answer: D
Rationale: Allopurinol reduces serum uric acid levels, indicating therapeutic effectiveness in preventing uric acid stone formation.
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
Postoperative nursing care for a client after an appendectomy should include which of the following?
- A. Administering sitz baths four times a day.
- B. Noting the first bowel movement after surgery.
- C. Limiting the client's activity to bathroom privileges.
- D. Measuring abdominal girth every 2 hours.
Correct Answer: B
Rationale: Noting the first bowel movement after an appendectomy is important to confirm the return of bowel function. Sitz baths, limited activity, or measuring girth are not standard post-appendectomy care. CN: Physiological adaptation; CL: Synthesize