Nokea
A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections.
- B. Vitamin B6 injections.
- C. An antibiotic.
- D. An antacid.
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is necessary for the absorption of vitamin B12 in the intestines. Therefore, the client with this disorder will need vitamin B12 injections to bypass the need for intrinsic factor.
Choice B (Vitamin B6 injections) is incorrect because pernicious anemia specifically involves a deficiency in vitamin B12, not B6. Choice C (An antibiotic) is incorrect as antibiotics are not indicated for pernicious anemia. Choice D (An antacid) is also incorrect as it does not address the underlying issue of vitamin B12 deficiency caused by the lack of intrinsic factor.
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The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?
- A. Leukopenia with a shift to the right
- B. Leukocytosis with a shift to the right
- C. Leukocytosis with a shift to the left
- D. Leukopenia with a shift to the left
Correct Answer: C
Rationale: The correct answer is C: Leukocytosis with a shift to the left. In acute appendicitis, the body responds with an increase in white blood cells (leukocytosis) as a sign of infection. A shift to the left indicates an increase in immature neutrophils, which is a common response to acute bacterial infections like appendicitis. Leukopenia (choices A and D) would not be expected in appendicitis. Leukopenia is a decrease in white blood cells, which is not typical in an acute infection like appendicitis. Leukocytosis with a shift to the right (choice B) could be seen in chronic infections or conditions like leukemia, not in acute appendicitis where a shift to the left is more common due to the rapid response to infection.
The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?
- A. Stop the flow of solution temporarily.
- B. Reposition the client on to her right side.
- C. Remove the irrigation tube.
- D. Massage the abdomen gently.
Correct Answer: A
Rationale: The correct response is A: Stop the flow of solution temporarily. This is the appropriate action to take first in this situation to prevent further complications. By stopping the flow of the solution, the nurse can assess the client's condition and determine the cause of the abdominal cramping. Repositioning the client (B) or massaging the abdomen (D) may exacerbate the cramping if there is an underlying issue. Removing the irrigation tube (C) without proper assessment could lead to complications. It is essential to prioritize the client's safety and well-being by halting the irrigation process to address any immediate concerns.
The client with cirrhosis has ascites and excess fluid volume. Which measure will the nurse include in the plan of care for this client?
- A. Increase the amount of sodium in the diet.
- B. Limit the amount of fluids consumed.
- C. Encourage frequent ambulation.
- D. Administer magnesium antacids.
Correct Answer: B
Rationale: The correct answer is B: Limit the amount of fluids consumed. In cirrhosis with ascites and excess fluid volume, limiting fluid intake helps reduce fluid overload and prevent further accumulation of fluid in the body. Excess fluid can worsen ascites, leading to complications like respiratory distress and electrolyte imbalances. Increasing sodium intake (A) would worsen fluid retention. Encouraging ambulation (C) is important but not directly related to managing ascites. Administering magnesium antacids (D) is not necessary for addressing fluid volume excess.
The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
- A. Continuing to advance the tube to the desired distance
- B. Pulling the tube back slightly
- C. Checking the back of the pharynx using a tongue blade and flashlight.
- D. Instructing the client to breathe slowly and take sips of water.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. The client is experiencing coughing, gagging, and choking, indicating improper tube insertion.
2. Continuing to advance the tube can lead to further discomfort and potential complications.
3. Pulling the tube back slightly allows for reevaluation of placement and prevents further irritation.
4. Checking the back of the pharynx can identify any obstruction or incorrect placement.
5. Instructing the client to breathe slowly and take sips of water can help relax the client and facilitate proper insertion.
A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?
- A. High-fat with milk
- B. High-protein without milk
- C. Low-roughage without milk
- D. Low-roughage with milk
Correct Answer: C
Rationale: The correct answer is C: Low-roughage without milk. In mild cases of ulcerative colitis, a low-roughage diet is recommended to reduce irritation to the colon. Roughage can exacerbate symptoms. Avoiding milk is also common as lactose intolerance may develop. High-fat (A) and high-protein (B) diets can be difficult to digest and may worsen symptoms. Low-roughage with milk (D) is incorrect as milk can irritate the colon in some individuals with ulcerative colitis.