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A client with cirrhosis is about to have a paracentesis for relief of ascites. Which activity is essential prior to the procedure?
- A. Administer thorough mouth care.
- B. Ask the client to empty his bladder.
- C. Be sure his bowels have moved recently.
- D. Have the client bathe with betadine.
Correct Answer: B
Rationale: Emptying the bladder prevents accidental puncture during paracentesis, which involves inserting a needle into the abdominal cavity.
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Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series?
- A. Chalky white stools.
- B. Increased heart rate.
- C. A firm, hard abdomen.
- D. Hyperactive bowel sounds.
Correct Answer: A
Rationale: A UGI series uses barium, which can cause chalky white stools as it is excreted. Heart rate, abdominal firmness, and bowel sounds are not typically affected.
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
- A. The stoma should be a white, blue, or purple color.
- B. Limit ambulation to prevent the pouch from coming off.
- C. Take pain medication when the pain level is at an '8.'
- D. Empty the pouch when it is one-third to one-half full.
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
- A. No bowel movement.
- B. Oxygen saturation 96%.
- C. Vital signs within normal baseline.
- D. Intact gag reflex.
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
The public health nurse is teaching day-care workers. Which type of hepatitis is transmitted by the fecal-oral route via contaminated food, water, or direct contact with an infected person?
- A. Hepatitis A.
- B. Hepatitis B.
- C. Hepatitis C.
- D. Hepatitis D.
Correct Answer: A
Rationale: Hepatitis A is transmitted via the fecal-oral route through contaminated food, water, or contact, common in settings like daycares. Other types are bloodborne or require co-infection.