Nokea
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.
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A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?
- A. To stabilize fluid and electrolyte balance.
- B. To minimize oxygen consumption.
- C. To increase client and family comfort.
- D. To prevent infection.
Correct Answer: B
Rationale: A dimly lit environment and limited visitors reduce stimulation, minimizing oxygen consumption in a client with gastric bleeding, who may be hypoxic due to anemia. Comfort is secondary, and these measures do not directly stabilize fluids or prevent infection.
A client post-inguinal herniorrhaphy reports scrotal swelling 24 hours after surgery. Which action should the nurse take first?
- A. Apply a warm compress to the scrotum.
- B. Notify the surgeon.
- C. Elevate the scrotum and apply ice.
- D. Administer a diuretic as ordered.
Correct Answer: C
Rationale: Elevating the scrotum and applying ice is the first action to reduce scrotal swelling post-inguinal herniorrhaphy, a common postoperative finding. Warm compresses may worsen swelling, notification is needed if swelling persists, and diuretics are not indicated. CN: Physiological adaptation; CL: Synthesize
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.