Nokea
An adult has both an oil retention enema and a cleansing enema ordered. The nurse knows that this client is most likely to have which condition/ problem?
- A. Straining while defecating
- B. Melena
- C. Ulcerative colitis
- D. Fecal impaction
Correct Answer: D
Rationale: Oil retention enemas soften hardened stool, and cleansing enemas remove it, making this combination most appropriate for fecal impaction. Straining, melena, or ulcerative colitis are less likely to require both types of enemas.
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The nurse is caring for a client who had thoracic surgery yesterday and has a chest tube attached to water seal drainage. The client's family asks why he has to have a chest tube. What should the nurse include in the response?
- A. The chest tube allows air to enter the thoracic cavity to equalize pressures in the lung.
- B. The chest tube removes air from the pleural cavity and promotes reexpansion of the lung.
- C. The chest tube increases the amount of oxygen available to the lungs.
- D. The chest tube will help the wound heal faster and reduce scarring.
Correct Answer: B
Rationale: Chest tubes remove air/fluid from the pleural cavity, allowing lung reexpansion post-thoracic surgery. Other options misrepresent the tube's function.
The nurse is providing pin site care for an adult who is in skeletal traction. What should the nurse do when providing pin site care?
- A. Clean the pin site with alcohol
- B. Clean the pin site with hydrogen peroxide
- C. Clean the pin site with betadine and apply steroid ointment as ordered
- D. Clean the pin site with soap and water and apply antibiotic ointment as ordered
Correct Answer: D
Rationale: Pin site care involves cleaning with soap and water to prevent infection and applying antibiotic ointment as ordered to reduce bacterial growth, per standard protocols.
The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?
- A. Slow the IV and raise the head of the bed
- B. Call the physician
- C. Take the client's blood pressure
- D. Notify the charge nurse
Correct Answer: A
Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.
A client is admitted to the coronary care unit with an acute myocardial infarction. The pain associated with acute myocardial infarction results from:
- A. Spasm of the coronary artery
- B. Ischemia of the myocardium
- C. Vasodilation of the coronary veins
- D. Ischemia of the carotid artery
Correct Answer: B
Rationale: Myocardial infarction pain is caused by ischemia of the myocardium due to reduced blood flow, leading to tissue hypoxia.
The nurse is screening clients for those at risk for developing endometrial cancer. Which of the following clients is at highest risk for developing endometrial cancer?
- A. 42-year-old client who has been taking a progestin-containing oral contraceptive for 10 years
- B. 45-year-old client who has a history of one ectopic pregnancy and two births
- C. 51-year-old client who has polycystic ovary syndrome and is obese
- D. 54-year-old client who has a history of hysterectomy for uterine fibroids
Correct Answer: C
Rationale: Obesity and polycystic ovary syndrome (PCOS) increase endometrial cancer risk due to excess estrogen from adipose tissue and anovulation. Ectopic pregnancy and births are not significant risk factors.