Nokea
A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply.
- A. Projectile vomiting.
- B. Significant abdominal distention.
- C. Copious diarrhea.
- D. Rapid onset of dehydration.
- E. Increased bowel sounds.
Correct Answer: A,B,D,E
Rationale: Small intestinal obstruction can cause projectile vomiting (A), abdominal distention (B), rapid dehydration (D) due to fluid loss, and increased bowel sounds (E) proximal to the obstruction. Copious diarrhea (C) is less likely as stool passage is blocked. CN: Physiological adaptation; CL: Analyze
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The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation?
- A. Combination chemotherapy is used to interrupt cell growth cycle at different points.'
- B. Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.'
- C. Combination chemotherapy is used to decrease resistance.'
- D. Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent.'
Correct Answer: B
Rationale: Combination chemotherapy targets cancer cells at different cell cycle stages, reduces resistance, and minimizes toxicity by using lower doses of multiple drugs. It does not treat side effects; supportive care does. This statement indicates a need for further explanation.
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
- A. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet
- B. Decreasing the pain by producing analgesia
- C. Increasing the blood supply to the affected area
- D. Increasing monoamine oxidase
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
The nurse will anticipate which of the following problems that can result for the older adult undergoing abdominal surgery?
- A. Uncrossed scarring.
- B. Decreased melanin and melanocytes.
- C. Decreased healing.
- D. Increased immunocompetence.
Correct Answer: C
Rationale: Older adults have slower wound healing due to reduced collagen synthesis and cellular turnover, increasing the risk of delayed recovery post-surgery.