Nokea
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.
You may also like to solve these questions
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.
A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am only contagious while the lesions are present.
- B. The virus cannot spread to areas other than the genital area.
- C. I can have unprotected sex as long as I am taking acyclovir.
- D. The lesions may reoccur in times of stress.
Correct Answer: D
Rationale: Herpes simplex virus type 2 can recur during stress due to immune suppression, indicating client understanding.
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can decrease my risk for a stroke by losing excess weight.
- B. My risk for a stroke increases if my HbA1c level is 5 percent or less.
- C. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.
- D. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.
Correct Answer: A
Rationale: Losing excess weight reduces risk factors such as hypertension and diabetes complications, which are linked to stroke risk, indicating understanding of the teaching.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Season foods with spices.
- C. Provide a high-calorie diet.
- D. Administer an antiemetic after each meal.
Correct Answer: C
Rationale: A high-calorie diet addresses malnutrition in AIDS clients, supporting nutritional needs and immune function.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Monitor the client for weight.
- B. Check the client for increased hypopigmentation under the patch.
- C. Advise the client about increased dry mouth.
- D. Inform the client of the adverse effect of diarrhea.
Correct Answer: C
Rationale: Clonidine can cause dry mouth as a common side effect, and advising the client about this is appropriate for the plan of care.