Nokea
A client with colon cancer had a left hemicolectomy 3 weeks previously. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. Which of the following nutritional support methods would be most appropriate?
- A. Total parenteral nutrition through a central catheter.
- B. I.V. infusion of dextrose.
- C. Nasogastric feeding tube with protein supplement.
- D. Jejunostomy for high caloric feedings.
Correct Answer: C
Rationale: A nasogastric feeding tube with protein supplement is appropriate for short-term nutritional support post-hemicolectomy, as it delivers nutrients directly to the stomach while the client's oral intake improves.
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The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.
The nurse is assessing a client who has a suspected retinal detachment. Which of the following client statements would be consistent with this diagnosis?
- A. My vision has a cloudy appearance.'
- B. I have intense pain above my eyebrow.'
- C. I am having difficulty seeing while driving at night.'
- D. I can see bright flashes of light.'
Correct Answer: D
Rationale: Bright flashes of light are a hallmark symptom of retinal detachment due to vitreoretinal traction. Cloudy vision is more typical of cataracts, intense pain is not common, and night vision difficulty is not specific to retinal detachment.
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the chart. Which action would be most appropriate for the nurse to implement?
- A. Wearing a protective gown and particulate respiratory mask when completing treatments.
- B. Washing hands before and after entering the room.
- C. Restricting visitors.
- D. Contacting the physician for an order for hematopoietic factors such as erythropoietin (Epogen, Procrit).
Correct Answer: B
Rationale: With a low white blood cell count (1,600/mm³) and absolute neutrophil count (<1,000/mm³), hand washing before and after entering the room is critical to prevent infection in this neutropenic client.
A Stage II pressure ulcer is characterized by:
- A. Redness in the involved area.
- B. Muscle spasms in the involved area.
- C. Pain in the involved area.
- D. Tissue necrosis in the involved area.
Correct Answer: C
Rationale: Stage II pressure ulcers cause pain due to partial-thickness skin loss and exposed nerve endings. Redness is Stage I, and necrosis is Stage III or IV.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate?
- A. Placing a pillow in the axilla so the arm is away from the body.
- B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
- C. Immobilizing the extremity in a sling.
- D. Positioning a hand cone in the hand so the fingers are barely flexed.
- E. Keeping the arm at the side using a pillow.
Correct Answer: A,D
Rationale: Placing a pillow in the axilla (A) prevents adduction contractures, and a hand cone (D) maintains slight finger flexion to avoid claw-hand deformity. A sling or keeping the arm at the side may promote contractures, and elevating the hand above the elbow is less critical.