Nokea
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
- A. Administer antihypertensive medications.
- B. Maintain the client on NPO status.
- C. Place the client in a supine position.
- D. Monitor the client for hypercalcemia.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on NPO status. In acute pancreatitis, the pancreas is inflamed, and digestion should be minimized to reduce pancreatic enzyme secretion. Keeping the client on NPO status allows the pancreas to rest and reduces stimulation of enzyme production. Administering antihypertensive medications (A) is not directly related to pancreatitis care. Placing the client in a supine position (C) may not be comfortable and can exacerbate pain. Monitoring for hypercalcemia (D) is important in chronic pancreatitis but not typically a priority in acute cases.
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A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?
- A. I can take another dose after 2 minutes.
- B. I can put the tablet against my cheek and gum.
- C. I should chew the tablet before I swallow it.
- D. I should take this medication as soon as the pain begins.
Correct Answer: D
Rationale: The correct answer is D: "I should take this medication as soon as the pain begins." This is correct because nitroglycerin is a rapid-acting medication used to relieve chest pain associated with angina. Taking it at the onset of chest pain helps dilate blood vessels and improve blood flow to the heart muscle.
Choice A is incorrect because taking another dose after 2 minutes could lead to overdose and hypotension. Choice B is incorrect as the tablet should be placed under the tongue, not against the cheek and gum. Choice C is incorrect because nitroglycerin should not be chewed but allowed to dissolve under the tongue.
A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
Correct Answer:
Rationale: Correct Answer: B
Rationale: The correct location to assess the stoma following a transverse colon resection with colostomy placement is at location B, which is in the left lower quadrant. This is because the transverse colon is typically located in the upper abdomen, and the stoma would be brought out at the most dependent portion of the colon, which is in the left lower quadrant. Assessing the stoma in this location allows the nurse to monitor for proper stoma function and potential complications.
Summary:
A: Incorrect - Location A is in the right upper quadrant, which is not the typical site for a stoma following a transverse colon resection.
C: Incorrect - Location C is in the left upper quadrant, which is also not the typical site for a stoma after this surgery.
D, E, F, G: Not applicable as they are not relevant to the question.
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
- A. Ask a family member to be present during the admission.
- B. Request an interpreter during the initial assessment.
- C. Familiarize themselves with commonly used sign language.
- D. Obtain a board that uses colored pictures as communication.
Correct Answer: B
Rationale: The correct answer is B: Request an interpreter during the initial assessment. This is the most appropriate action as it ensures effective communication between the nurse and the client who uses sign language. It upholds the client's right to clear and accurate information regarding their care. Asking a family member (choice A) may not guarantee accurate communication and could breach confidentiality. Familiarizing oneself with sign language (choice C) takes time and may not be sufficient for complex medical discussions. Using a board with pictures (choice D) may not provide the client with the level of detail needed for comprehensive care. Overall, requesting an interpreter is the best choice for ensuring effective communication and respecting the client's rights.
A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?
- A. Gag reflex
- B. Warmth of extremities
- C. Temperature
- D. Level of pain
Correct Answer: A
Rationale: The correct answer is A: Gag reflex. The priority assessment for a client post-endoscopy with sedation is to ensure their airway is intact. The presence of a gag reflex indicates the airway protection mechanism is functional, reducing the risk of aspiration. Monitoring warmth of extremities, temperature, and pain level are important but secondary assessments compared to airway patency. Ensuring the client's safety and preventing respiratory compromise take precedence in this situation.
A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
- A. Discard the radioactive device in the client's trash can.
- B. Limit time for visitors to 2 hr per day.
- C. Instruct visitors to remain 3 feet from the client.
- D. Keep soiled bed linens in the client's room.
Correct Answer: C
Rationale: The correct answer is C: Instruct visitors to remain 3 feet from the client. This is because brachytherapy involves the internal placement of radioactive sources close to the tumor. By instructing visitors to remain 3 feet away, the nurse helps minimize their exposure to radiation.
A: Discarding the radioactive device in the client's trash can is incorrect as it can pose a radiation hazard to others.
B: Limiting time for visitors to 2 hours per day does not directly address radiation exposure concerns.
D: Keeping soiled bed linens in the client's room does not address radiation safety for visitors.
In summary, option C is the best choice as it directly addresses radiation safety for visitors during brachytherapy treatment.