Nokea
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.
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The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.
Which of the following NSAIDS is most commonly used for a brief time for acute pain?
- A. Advil
- B. Aleve
- C. Toradol
- D. Bextra
Correct Answer: C
Rationale: Toradol (ketorolac) is frequently used for short-term acute pain management due to its potent analgesic effects, administered IM, IV, or PO.
Which of these types of fluid output is not typically measured?
- A. chest tube drainage
- B. emesis
- C. evaporative water from the respiratory tract
- D. urine
Correct Answer: C
Rationale: Evaporative water from respiration is a form of insensible loss and is typically not measured.
Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.