Nokea
After a subtotal gastrectomy, the nasogastric tube drainage will be what color for about 12 to 24 hours after surgery?
- A. Dark brown.
- B. Bile green.
- C. Bright red.
- D. Cloudy white.
Correct Answer: C
Rationale: Nasogastric tube drainage is typically bright red for 12 to 24 hours post-gastrectomy due to surgical bleeding, gradually changing as bleeding subsides.
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A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
- A. Palpitations.
- B. Tinnitus.
- C. Urinary frequency.
- D. Lethargy.
Correct Answer: B
Rationale: Tinnitus is a sign of lidocaine toxicity, requiring further assessment to prevent serious complications like seizures or arrhythmias.
The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan?
- A. Hepatitis B is relatively uncommon among college students.
- B. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B.
- C. Good personal hygiene habits are most effective at preventing the spread of hepatitis B.
- D. The use of a condom is advised for sexual intercourse.
Correct Answer: D
Rationale: Condom use (D) prevents hepatitis B transmission via sexual contact. Hepatitis B is not uncommon in college students (A). Alcohol (B) is unrelated to hepatitis B transmission. Hygiene (C) is less effective than barrier protection.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) increases ammonia production, precipitating hepatic encephalopathy. Aldosterone (A), creatinine (B), and protein (D) are not directly linked to this condition's onset.
The nurse is checking the laboratory results on a 52-year-old client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed?
- A. Blood glucose.
- B. Total cholesterol.
- C. Hemoglobin.
- D. Low-density lipoprotein (LDL) cholesterol.
Correct Answer: A
Rationale: Elevated blood glucose in type 1 diabetes indicates poor glycemic control, requiring immediate management to prevent complications like ketoacidosis.