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A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
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A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
- A. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days
- B. Heart rate of 100 beats per minute after ambulating 200 feet
- C. Urine output of 2,000 mL in 24 hours
- D. Weakness and numbness in the lower extremities
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
Which of the following guidelines reflects the current American Cancer Society recommendations for screening for colon cancer in individuals who are not at high risk?
- A. Annual digital rectal examination should begin at age 40.
- B. Annual fecal testing for occult blood should begin at age 50.
- C. Individuals should obtain a baseline barium enema at age 40.
- D. Individuals should obtain a baseline colonoscopy at age 45.
Correct Answer: B
Rationale: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they recommend the nurse to the need for such diagnostic testing, or are considered to be at high risk. CN: Health promotion and maintenance; CL: Apply
A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs?
- A. Arms.
- B. Legs.
- C. Abdomen.
- D. Iliac crest.
Correct Answer: C
Rationale: The abdomen is the preferred insulin injection site for active individuals like joggers, as it provides consistent absorption and is less affected by exercise compared to the legs.
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim:
- A. Starts to become cyanotic.
- B. Cannot speak due to airway obstruction.
- C. Can make only minimal vocal noises.
- D. Is coughing vigorously.
Correct Answer: B
Rationale: Inability to speak indicates a complete airway obstruction, necessitating the Heimlich maneuver to dislodge the blockage.
The nurse is monitoring a client who received ketamine for anesthesia induction. Which side effect should the nurse prioritize?
- A. Hypotension.
- B. Respiratory depression.
- C. Vivid dreams or hallucinations.
- D. Bradycardia.
Correct Answer: C
Rationale: Ketamine can cause vivid dreams or hallucinations, which may distress the client during recovery. Monitoring and reassuring the client are critical to manage this psychological side effect.