Nokea
An adult postoperative client vomits, and his abdominal wound eviscerates. What is the best initial action for the nurse to take?
- A. Cover the exposed coils of intestine with sterile moist towels or dressings
- B. Pack the intestines back into the abdominal cavity
- C. Irrigate the exposed coils of intestines with sterile water
- D. Take the client's vital signs
Correct Answer: A
Rationale: Covering exposed intestines with sterile moist dressings prevents infection and drying of tissue, stabilizing the client until surgical intervention. Packing intestines risks contamination, irrigation is inappropriate, and vital signs are secondary to immediate protection.
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The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .
A client with cancer tells the nurse that he would like to make out a living will. The nurse knows that a living will provides documentation of:
- A. The client's desire to receive all means of assistance to sustain life.
- B. The client's desire to allow another to make decisions regarding his care.
- C. The client's wish to die without life-prolonging interventions.
- D. The client's desire to have his life terminated by active euthanasia.
Correct Answer: C
Rationale: A living will documents a client's wish to avoid life-prolonging interventions in terminal conditions. It does not mandate all assistance, delegate decisions, or support euthanasia.
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.