Nokea
A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following interventions would be most appropriate?
- A. Explain that high-fat diets usually are tolerated better.
- B. Encourage intake of foods high in protein.
- C. Explain that the majority of calories need to be consumed in the evening hours.
- D. Monitor for fluid and electrolyte imbalance.
Correct Answer: D
Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. Explaining to the client that the majority of calories should be eaten in the morning hours is important because nausea occurs most often in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are tolerated better.
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The client has orders for a nasogastric (NG) tube insertion. During the procedure, instructions that will assist in the insertion would be:
- A. Instruct the client to tilt his head back for insertion in the nostril, then flex his neck for the final insertion
- B. After insertion into the nostril, instruct the client to extend his neck
- C. Introduce the tube with the client's head tilted back, then instruct him to keep his head upright for final insertion
- D. Instruct the client to hold his chin down, then back for insertion of the tube
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid?
- A. I should take my antacid before I take my other medications.
- B. I need to decrease my intake of fluids so that I don't dilute the effects of my antacid.
- C. My antacid will be most effective if I take it whenever I experience stomach pains.
- D. It is best for me to take my antacid 1 to 3 hours after meals.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following measures should the nurse focus on for the client with esophageal varices?
- A. Recognizing hemorrhage
- B. Controlling blood pressure
- C. Encouraging nutritional intake
- D. Teaching the client about varices
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?
- A. Have the client drink 1000 mL of water.
- B. Ask the client about possible allergies to iodine or shellfish.
- C. Administer an intravenous contrast agent the evening before the test.
- D. Administer tap-water enemas until clear.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client with peptic ulcer disease is scheduled for a pyloroplasty. The client asks the nurse about the procedure. The nurse plans to respond knowing that a pyloroplasty involves:
- A. Cutting the vagus nerve
- B. Removing the distal portion of the stomach
- C. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid
- D. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.