Nokea
A nurse is caring for a patient who is postoperative following a cholecystectomy. Which of the following findings should the nurse report to the provider? Which finding post-cholecystectomy should the nurse report?
- A. Clay-colored stools
- B. Mild abdominal pain
- C. Nausea
- D. Fatigue
Correct Answer: A
Rationale: Correct Answer: A: Clay-colored stools
Rationale: Clay-colored stools can indicate a potential issue with bile flow, which is crucial post-cholecystectomy. Absence of bile in the stool may suggest a blocked bile duct, leading to complications like jaundice or infection. This finding should be reported promptly for further evaluation and management.
Summary of other choices:
- B: Mild abdominal pain is common post-surgery and can be managed with pain medications.
- C: Nausea is also expected after surgery and can be managed with antiemetics.
- D: Fatigue is a common postoperative symptom and may improve with rest and proper nutrition.
You may also like to solve these questions
A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period. The child weighs 33 lb. Which of the following actions should the nurse take? What should the nurse do for low urine output?
- A. Notify the provider.
- B. Continue to monitor the client.
- C. Perform a bladder scan at the bedside.
- D. Provide oral rehydration fluids.
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. In a 3-year-old child, the average expected urine output is about 1-2 ml/kg/hour. Given the child's weight of 33 lb (approximately 15 kg), the expected urine output over 8 hours would be around 120-240 ml. The child's output of 160 ml falls within this expected range, indicating adequate hydration. Therefore, the nurse should continue monitoring the client for any changes.
Incorrect choices:
A: Notifying the provider is not necessary as the urine output is within the expected range.
C: Performing a bladder scan is not indicated as there is no indication of urinary retention.
D: Providing oral rehydration fluids is not necessary since the child's urine output is adequate.
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following patients should the nurse identify as requiring airborne precautions? Which patient requires airborne precautions?
- A. A patient who has streptococcal pharyngitis
- B. A patient who has scabies
- C. A patient who has measles
- D. A patient who has pertussis
Correct Answer: C
Rationale: The correct answer is C: A patient who has measles. Measles is a highly contagious airborne disease spread through respiratory droplets. Airborne precautions are necessary to prevent transmission. Streptococcal pharyngitis (A) is spread through direct contact or respiratory droplets, not airborne. Scabies (B) is transmitted through skin-to-skin contact, not airborne. Pertussis (D) is spread through respiratory droplets, but not as easily as measles, so airborne precautions are not typically required.
A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect? What finding should the nurse expect in left-sided heart failure?
- A. Frothy sputum
- B. Dependent edema
- C. Nocturnal polyuria
- D. Jugular distention
Correct Answer: A
Rationale: The correct answer is A: Frothy sputum. In left-sided heart failure, the failing left ventricle results in blood backing up into the lungs causing pulmonary congestion. This leads to the production of frothy, pink-tinged sputum due to blood-tinged fluid leaking into the alveoli. Dependent edema (choice B) is more indicative of right-sided heart failure. Nocturnal polyuria (choice C) is not a typical finding in left-sided heart failure. Jugular distention (choice D) is more commonly seen in right-sided heart failure due to increased venous pressure.
A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.
A nurse is caring for a patient who has a new prescription for clonazepam. Which of the following instructions should the nurse include? What instructions should the nurse include for clonazepam?
- A. Avoid alcohol consumption.
- B. Take the medication with food.
- C. Increase fluid intake.
- D. Report any weight gain.
Correct Answer: A
Rationale: The correct answer is A: Avoid alcohol consumption. Clonazepam is a central nervous system depressant and can cause additive sedative effects when combined with alcohol, leading to increased drowsiness and impaired coordination. This can be dangerous and increase the risk of accidents or overdose. Therefore, it is essential for the nurse to instruct the patient to avoid alcohol consumption while taking clonazepam.
For the other choices:
B: Taking the medication with food is not specifically required for clonazepam administration.
C: Increasing fluid intake is not directly related to clonazepam use.
D: Reporting any weight gain is important for some medications, but it is not a specific concern with clonazepam.
Overall, the key instruction for the nurse to provide is avoiding alcohol consumption to ensure the safe and effective use of clonazepam.