Nokea
After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?
- A. Irrigate the wound & organs with Betadine.
- B. Cover the wound with a saline soaked sterile dressing.
- C. Apply a dry sterile dressing & binder.
- D. Push the organs back & cover with moist sterile dressings.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Regina is a 46 y.o. woman with ulcerative colitis. You expect her stools to look like:
- A. Watery and frothy.
- B. Bloody and mucoid.
- C. Firm and well-formed.
- D. Alternating constipation and diarrhea.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Gail is scheduled for a cholecystectomy. After completion of preoperative teaching, Gail states,"If I lie still and avoid turning after the operation, I'll avoid pain. Do you think this is a good idea?" What is the best response?
- A. You'll need to turn from side to side every 2 hours.
- B. It's always a good idea to rest quietly after surgery.
- C. The doctor will probably order you to lie flat for 24 hours.
- D. Why don't you decide about activity after you return from the recovery room?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You're caring for Jane, a 57 y.o. patient with liver cirrhosis who develops ascites and requires paracentesis. Before her paracentesis, you instruct her to:
- A. Empty her bladder.
- B. Lie supine in bed.
- C. Remain NPO for 4 hours.
- D. Clean her bowels with an enema.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct Answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
Glenda has cholelithiasis (gallstones). You expect her to complain of:
- A. Pain in the right upper quadrant, radiating to the shoulder.
- B. Pain in the right lower quadrant, with rebound tenderness.
- C. Pain in the left upper quadrant, with shortness of breath.
- D. Pain in the left lower quadrant, with mild cramping.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.