Nokea
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.
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A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
For each finding. click to specify if the finding is consistent with pancreatitis or peritonitis Each finding may support more than one disease process.
- A. Bloody stools
- B. Hyperbilirubinemia
- C. Abdominal pain
- D. Elevated WBC court
Correct Answer: A,B,C,D
Rationale: The correct answer is .
Rationale:
1. Bloody stools can be seen in both pancreatitis and peritonitis due to gastrointestinal bleeding.
2. Hyperbilirubinemia is a common finding in pancreatitis due to obstruction of the bile duct by edema or inflammation.
3. Abdominal pain is a hallmark symptom of both pancreatitis and peritonitis, indicating inflammation or irritation of the abdominal structures.
4. Elevated WBC count is a sign of infection or inflammation, which can be present in both pancreatitis and peritonitis.
Summary:
- Bloody stools: Supports both pancreatitis and peritonitis.
- Hyperbilirubinemia: Supports pancreatitis.
- Abdominal pain: Supports both pancreatitis and peritonitis.
- Elevated WBC count: Supports both pancreatitis and peritonitis.
Other choices are incorrect because they do not align with the typical clinical presentations of pancreatitis
Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
Which of the following actions should the nurse plan to take?
- A. Launch a media campaign to increase awareness about industrial pollution
- B. Have a nurse from outside the community provide health lectures at the county hospital
- C. Encourage rural residents to focus health spending on tertiary health interventions
- D. Provide anticipatory guidance classes to parents through public schools
Correct Answer: D
Rationale: The correct answer is D because providing anticipatory guidance classes to parents through public schools is a proactive approach to promote health and prevent illness in the community. This action empowers parents with knowledge and skills to make informed health decisions for their children. Launching a media campaign (A) may raise awareness but may not directly impact individual behavior change. Having a nurse from outside the community provide health lectures (B) may not be as effective as someone familiar with the community's specific needs. Encouraging rural residents to focus on tertiary health interventions (C) is reactive and may not address prevention.
Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation
- B. Osteoarthritis
- C. Hypertension
- D. Primary glaucoma
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is a contraindication to many medical procedures due to the increased risk of complications such as bleeding or cardiovascular events. In this case, performing a procedure on a child with hypertension could pose significant risks to their health. Amputation (A) is not necessarily a contraindication unless it directly affects the procedure site. Osteoarthritis (B) may not directly impact the procedure. Primary glaucoma (D) is not related to the procedure in question.