Nokea
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
- A. Peritonitis.
- B. Thrombophlebitis.
- C. Ingestes.
- D. Inguinal hernia.
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.
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The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
- A. Heart rate 57 bpm
- B. SpO2 of 94% on room air
- C. Blood pressure in 1 mm/s
- D. Ankle brachial index of 0.65
Correct Answer: D
Rationale: An ankle-brachial index (ABI) of 0.65 is significantly below the normal range (0.9–1.3), indicating potential peripheral vascular disease (PVD) due to arterial insufficiency. This finding warrants further evaluation, especially given the client's symptoms of claudication (pain during exercise relieved by rest) and smoking history, which are risk factors for PVD. The other options€”heart rate, SpO2, and blood pressure€”are either normal or irrelevant in this context.
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
- A. Assess heart sounds.
- B. Obtain an order for blood cultures.
- C. Prepare for a paracentesis.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (D) improves breathing. Heart sounds (A), blood cultures (B), and paracentesis (C) are secondary.
A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which the patient is the client should demonstrate to the nurse that the client understands the instructions?
- A. I should limit the use of the inhaler to early morning and bedtime use.
- B. It is important to not shake the canister because that can damage the spray device.
- C. I should hold one nostril closed while I insert the spray into the other nostril.
- D. The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.
Correct Answer: C
Rationale: Holding one nostril closed while spraying into the other ensures proper delivery of the medication to the nasal mucosa. Limiting use to specific times is not typically required unless specified by the prescriber. Shaking the canister is often necessary for some inhalers to mix the medication. Pointing the inhaler toward the inner nostril wall is incorrect; it should be directed upward and slightly outward.
Which of the following is a priority outcome for the client with Addison's disease?
- A. Maintenance of medication compliance.
- B. Adherence to a 2-g sodium diet.
- C. Prevention of hypertensive episodes.
- D. Demonstration of effective coping skills.
Correct Answer: A
Rationale: Medication compliance is critical in Addison's disease to prevent adrenal crisis and maintain hormonal balance.
A terminally ill 82-year-old client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for conservative management of the nausea and vomiting, the nurse should recommend the use of:
- A. A nasogastric (NG) suction tube.
- B. I.V. antiemetics.
- C. Antibiotic laxatives.
- D. A clear liquid diet.
Correct Answer: B
Rationale: I.V. antiemetics are a conservative, effective way to manage nausea and vomiting in hospice care, aligning with the client's preference for non-invasive treatment.