Nokea
A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he:
- A. Passes stool without cramping.
- B. Does not have diarrhea any longer.
- C. Is not as anxious as he was.
- D. Does not expel gas like he used to.
Correct Answer: A
Rationale: Psyllium (Metamucil) is effective when the client passes stool without cramping, indicating improved bowel regularity and reduced irritation. Absence of diarrhea, anxiety, or gas are not primary indicators of its effectiveness. CN: Pharmacological and parenteral therapies; CL: Evaluate
You may also like to solve these questions
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
A middle-aged man collapses in the emergency department waiting room. The triage nurse should first:
- A. Gently shake the victim and ask him to state his name.
- B. Perform the chin-tilt to open the victim's airway.
- C. Feel for any air movement from the victim's nose or mouth.
- D. Watch the victim's chest for respirations.
Correct Answer: A
Rationale: The first step in assessing an unresponsive patient is to check for responsiveness by gently shaking and calling out to the victim, per AHA guidelines, to determine if CPR or other interventions are needed.
A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive?
Correct Answer: 24 mL/hour
Rationale: To calculate: (1,200 units/hour ÷ 25,000 units) × 500 mL = 24 mL/hour. This is a calculation question, not multiple-choice, so no choices or correct answer letter is provided.
A client with a recent total knee replacement reports swelling in the operative leg. Which nursing action is most appropriate?
- A. Elevate the leg on two pillows.
- B. Apply a warm compress to the knee.
- C. Encourage immediate ambulation.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Elevating the leg reduces swelling by promoting venous return, a standard post-surgical intervention.
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.