Nokea
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
- A. Clamp the urinary appliance at night.
- B. Empty the urinary appliance when one-third full.
- C. Administer prophylactic antibiotics.
- D. Change the urinary appliance daily.
Correct Answer: B
Rationale: Emptying the appliance when one-third full prevents urine stasis, reducing infection risk.
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A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?
- A. The neonate will need to be bottle-fed for the next few days.
- B. The condition typically is treated with I.V. antibiotic therapy.
- C. The client's uterus may become 'boggy,' requiring frequent massage and oxytocics.
- D. The client needs to remain in bed in a side-lying position as much as possible.
Correct Answer: B
Rationale: Endometritis is typically treated with I.V. antibiotics to address the infection.
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
A client is prescribed lansoprazole for the chronic management of Zollinger-Ellison syndrome. The nurse determines that the client best understands this disorder and the medication regimen when the client reports taking which product for pain?
- A. Naprosyn
- B. Ibuprofen
- C. Acetaminophen
- D. Acetylsalicylic acid
Correct Answer: C
Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should take acetaminophen for pain relief. The client should not take medications that irritate the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (naprosyn and ibuprofen).
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:
- A. Neutralizing gastric acid.
- B. Reducing gastric acid secretion.
- C. Coating the stomach lining.
- D. Increasing gastric motility.
Correct Answer: B
Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.