Nokea
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
- A. Inform his wife that he has returned to his room.
- B. Check to see if the indwelling urinary catheter bag is correctly attached to the bed frame.
- C. Assess to be sure he is not experiencing any discomfort.
- D. Put all four side rails in the high position.
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
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The nurse is discussing the therapeutic diet for the client diagnosed with diverticulosis. Which meal indicates the client understands the discharge teaching?
- A. Fried fish, mashed potatoes, and iced tea.
- B. Ham sandwich, applesauce, and whole milk.
- C. Chicken salad on whole-wheat bread and water.
- D. Lettuce, tomato, and cucumber salad and coffee.
Correct Answer: C
Rationale: A high-fiber diet, like whole-wheat bread, prevents constipation and flare-ups in diverticulosis. Fried foods, low-fiber applesauce, and salads with seeds (e.g., tomatoes) are less appropriate.
The female client came to the clinic complaining of abdominal cramping and at least 10 episodes of diarrhea every day for the last two (2) days. The client just returned from a trip to Mexico. Which intervention should the nurse implement?
- A. Instruct the client to take a cathartic laxative daily.
- B. Encourage the client to drink lots of Gatorade.
- C. Discuss the need to increase protein in the diet.
- D. Explain the client should weigh herself daily.
Correct Answer: B
Rationale: Frequent diarrhea risks dehydration and electrolyte loss; Gatorade replaces fluids and electrolytes. Laxatives worsen diarrhea, protein is secondary, and daily weights are less urgent.
The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?
- A. Takes the client’s vital signs every hour
- B. Walks the client 1 hour postprocedure
- C. Positions the client onto the right side
- D. Has the client cough and deep-breathe hourly
Correct Answer: C
Rationale: A. After a liver biopsy VS should be assessed every 15 minutes times two, every 30 minutes times four, and then every hour times four to monitor for shock, peritonitis, and pneumothorax. B. The client should be kept flat in bed for 12 to 14 hours following the procedure to prevent the risk of bleeding. C. Positioning the client on the right side after a liver biopsy splints the puncture site to prevent and decrease bleeding. D. The client should be cautioned to avoid coughing, which could precipitate bleeding.
A client is admitted to the hospital with a gnawing pain in the mid-epigastric area and black stools for the past week. A diagnosis of chronic duodenal ulcer is made. During the initial nursing assessment, the client makes all of the following statements. Which is most likely related to his admitting diagnosis?
- A. I am a vegetarian.'
- B. My mother and grandmother have diabetes.'
- C. I take aspirin several times a day for tension headaches.'
- D. I take multivitamin and iron tablets every day.'
Correct Answer: C
Rationale: Aspirin is very irritating to the gastric mucosa and is known to cause ulcers. Vegetarianism, family history of diabetes, and multivitamins with iron are not directly linked to duodenal ulcers.
The nurse writes a psychosocial problem of 'risk for altered sexual functioning related to new colostomy.' Which intervention should the nurse implement?
- A. Tell the client there should be no intimacy for at least three (3) months.
- B. Ensure the client and significant other are able to change the ostomy pouch.
- C. Demonstrate with charts possible sexual positions for the client to assume.
- D. Teach the client to protect the pouch from becoming dislodged during sex.
Correct Answer: D
Rationale: Teaching pouch protection during sex addresses practical concerns, supporting sexual function and confidence. A three-month intimacy ban is unnecessary, pouch changing is unrelated to sexual function, and charts may be less practical.