Nokea
A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Peripheral edema
- C. Decreased respirations
- D. Absent bowel sounds
Correct Answer: D
Rationale: Absent bowel sounds indicate paralytic ileus, a common finding in peritonitis due to inflammation. Polyuria, edema, and decreased respirations are not typical.
You may also like to solve these questions
A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?
- A. I'm going to take your heart rate.
- B. I need to give you diphenhydramine.
- C. Are you having difficulty breathing?
- D. Do you have any allergies to medications?
Correct Answer: C
Rationale: Asking about difficulty breathing is the priority as it assesses for anaphylaxis, a life-threatening allergic reaction to penicillin, requiring immediate intervention.
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Use a fire extinguisher at the source of the smoke.
- B. Close the doors to the room and to the bathroom.
- C. Activate the fire alarm system.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).
A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow.
- A. Wipe the sample port with an alcohol wipe and let the alcohol dry.
- B. Clamp the catheter tubing distal to the sampling port for 15 min.
- C. Attach a sterile needleless syringe to the sample port and aspirate the specimen
- D. Document in the client's electronic medical record that the specimen was sent to the laboratory.
- E. Empty the urine into a sterile container labeled with the client identifiers
Correct Answer: B,A,C,E,D
Rationale: Sequence: Clamp tubing (B) to collect urine, wipe port (A), aspirate with syringe (C), transfer to container (E), and document (D) for a sterile specimen.
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
- A. Insert a tampon following the procedure.
- B. Reinforce teaching that the procedure involves dilation of the cervix.
- C. Place the client in the Sims' position.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
A nurse is reinforcing teaching with a client who has iron-deficiency anemia. The nurse should instruct the client that which of the following foods has the highest iron content?
- A. 3 oz chicken breast
- B. 3 oz canned tuna
- C. 3 oz pork roast
- D. 3 oz ground beef
Correct Answer: D
Rationale: Ground beef has the highest iron content (about 2.7 mg/3 oz) among these options, making it best for iron-deficiency anemia.