Nokea
An adult is admitted to the nursing care unit. He begs the nurse to give him a laxative. Which data in the admission assessment contraindicates administration of a laxative?
- A. The client has not had a bowel movement for two days.
- B. The client has a temperature of 100.8°F.
- C. The client is nauseated and vomited before admission.
- D. The client has right lower quadrant abdominal pain.
Correct Answer: D
Rationale: Right lower quadrant pain may indicate appendicitis or other acute conditions; laxatives could worsen the condition, risking perforation. Two days without a bowel movement, mild fever, or nausea do not contraindicate laxatives.
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A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
- A. Which symptom should the nurse expect initially in a client with a subdural hematoma and cerebral edema?
- B. Unequal and dilated pupils.
- C. Decerebrate posturing.
- D. Grand mal seizures.
- E. Decreased level of consciousness.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.
An elderly client who has just had a prosthetic hip implant.
The nurse should position the client
- A. with the affected hip internally rotated and flexed.
- B. with the affected hip adducted when turned.
- C. in the supine position with the knees elevated 90°.
- D. side-lying with the affected hip in a position of abduction.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60°, adduction and internal rotation should be avoided in the early postoperative period (4) correct-position of abduction should be maintained
The nurse is preparing to change the dressing of a client with a venous access device. Because it is the first time the nurse has performed the skill, he reads the unit policy manual and asks another nurse how to best perform the dressing change. The skill level of the nurse at this time is best described as:
- A. Novice
- B. Proficient
- C. Competent
- D. Expert
Correct Answer: A
Rationale: A nurse performing a skill for the first time, relying on guidelines and assistance, is a novice. Higher levels require experience and independence.
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Which of the following actions by the nurse is MOST appropriate?
- A. Discontinue the heparin infusion.
- B. Slow down the heparin infusion.
- C. Check the prothrombin time (PT) results.
- D. Continue to monitor the client.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I).
- A. What should the nurse caution the client about to prevent dumping syndrome post-gastrectomy?
- B. Sit up for at least 30 minutes after eating.
- C. Avoid fluids between meals.
- D. Increase the intake of high-carbohydrate foods.
- E. Avoid eating large meals that are high in simple sugars and liquids.
Correct Answer: D
Rationale: To prevent dumping syndrome, the client should avoid large meals high in simple sugars and liquids, which can cause rapid gastric emptying. The client should recline after meals, drink fluids between meals, and reduce carbohydrate intake to stabilize digestion.