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A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be:
- A. Absent
- B. Hyperactive
- C. Normal
- D. Hypoactive
Correct Answer: A
Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.
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A client with type 2 diabetes mellitus is receiving metformin (Glucophage). Which laboratory test should the LPN/LVN monitor while the client is taking this medication?
- A. Complete blood count (CBC)
- B. Liver function tests
- C. Serum electrolytes
- D. Renal function tests
Correct Answer: B
Rationale: The correct answer is B: Liver function tests. While a client is taking metformin, monitoring liver function tests is crucial to assess for potential hepatic side effects. Metformin is primarily eliminated by the liver, and monitoring liver function tests helps in early detection of any liver-related complications. Choices A, C, and D are incorrect. A complete blood count (CBC) is not specifically required for monitoring metformin therapy. Serum electrolytes are not directly impacted by metformin, making it less relevant for monitoring this medication. Renal function tests are important for some other diabetes medications, but in the case of metformin, liver function tests take precedence due to its hepatic metabolism.
The healthcare professional is caring for a client with a chest tube. What is the most important action for the healthcare professional to take to ensure the chest tube is functioning properly?
- A. Milk the chest tube to ensure patency.
- B. Clamp the chest tube when moving the client.
- C. Ensure the water seal chamber is filled to the appropriate level.
- D. Secure the chest tube to the client's bed.
Correct Answer: C
Rationale: Ensuring the water seal chamber is filled to the appropriate level is crucial to maintain the effectiveness of the chest tube drainage system. This step helps prevent air from entering the pleural space, ensuring proper lung re-expansion. 'Milking' the chest tube is not recommended as it can cause damage to the chest tube and surrounding tissues. Clamping the chest tube is not advisable as it can lead to tension pneumothorax. Securing the chest tube to the bed is important for stability but does not directly impact the functioning of the chest tube.
A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
- B. I will use crutches to support my weight on my left leg.
- C. When ascending stairs, I will lead with my left leg.
- D. I will keep my crutches under my arms for support.
Correct Answer: A
Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.
A healthcare professional working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during their shift. Which of the following signatures may the healthcare professional legally witness?
- A. A 16-year-old client who is married
- B. A 27-year-old who has schizophrenia
- C. An adoptive parent who brings in their 8-year-old child
- D. A 17-year-old mother who brings in her toddler
Correct Answer: A
Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
- A. "It must be difficult to care for someone who is confined to bed."
- B. "It is important to keep the client clean to avoid infections."
- C. "I understand that this is challenging; let's work together to ensure comfort."
- D. "The smell is quite strong; we need to address this immediately."
Correct Answer: C
Rationale: The correct response is C: "I understand that this is challenging; let's work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.