Nokea
A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
- A. The client complains of a sore throat.
- B. The client displays signs of sedation.
- C. The client experiences a sudden increase in temperature.
- D. The client demonstrates a lack of appetite.
Correct Answer: C
Rationale: A sudden increase in temperature post-endoscopy may indicate a complication such as perforation or infection, requiring immediate assessment. Sore throat, sedation, and lack of appetite are expected or unrelated findings.
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If the client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
- A. Review the negative effects of smoking on the body.
- B. Discuss the effects of passive smoking on environmental pollution.
- C. Establish the client's daily smoking pattern.
- D. Explain how smoking worsens high blood pressure.
Correct Answer: C
Rationale: Establishing the daily smoking pattern identifies triggers and habits, forming the basis for a tailored cessation plan.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hypocalcemia.
- D. Disulfiram (Antabuse)-like symptoms.
Correct Answer: D
Rationale: Sulfonylureas combined with alcohol can cause disulfiram-like symptoms, such as flushing, nausea, and palpitations.
A client with a hip fracture is receiving heparin to prevent thromboembolism. Which laboratory value should the nurse monitor?
- A. Prothrombin time (PT).
- B. Activated partial thromboplastin time (aPTT).
- C. International Normalized Ratio (INR).
- D. Platelet count.
Correct Answer: B
Rationale: Heparin's effect is monitored via aPTT to ensure therapeutic anticoagulation.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.