Nokea
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. Which of the following is the most effective nursing intervention to relieve this discomfort?
- A. Encourage the client to ambulate.
- B. Insert a rectal tube.
- C. Insert a nasogastric (NG) tube.
- D. Encourage the client to drink carbonated liquids.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, relieving gas pains effectively and safely.
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The nurse is taking care of a client with Clostridium difficile (C. difficile). The nurse should do which of the following to prevent the spread of infection? Select all that apply.
- A. Wear a particulate respirator.
- B. Wear sterile gloves when providing care.
- C. Cleanse hands with alcohol-based hand sanitizer.
- D. Wash hands with soap and water.
- E. Wear a protective gown when in the client's room.
Correct Answer: D,E
Rationale: To prevent the spread of C. difficile, washing hands with soap and water (D) is essential as alcohol-based sanitizers are ineffective against its spores, and wearing a protective gown (E) prevents contamination. A respirator (A) is unnecessary, sterile gloves (B) are not required (clean gloves suffice), and alcohol sanitizer (C) is ineffective. CN: Safety and infection control; CL: Create
The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack?
- A. Occupational exposure to toxins.
- B. Viral respiratory infections.
- C. Exposure to cigarette smoke.
- D. Exercising in cold temperatures.
Correct Answer: B
Rationale: Viral respiratory infections are a leading trigger of acute asthma attacks due to airway inflammation. Toxins, smoke, and cold exercise are also triggers but less common.
The nurse teaches the client with chronic cancer pain about optimal pain control. Which of the following recommendations is most effective for pain control?
- A. Get used to some pain and use a little less medication than needed to keep from being addicted.
- B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.
- C. Take analgesics only when pain returns.
- D. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.
Correct Answer: B
Rationale: Taking analgesics around-the-clock prevents recurrent pain by maintaining steady drug levels, which is the most effective strategy for chronic cancer pain.
A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?
- A. Monitor the laboratory values.
- B. Observe neurologic function every 15 minutes.
- C. Observe the puncture site for swelling and bleeding.
- D. Monitor skin warmth and turgor.
Correct Answer: C
Rationale: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.
The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.
- A. Nausea and vomiting
- B. Constipation
- C. Pruritus
- D. Urinary retention
- E. Nystagmus
Correct Answer: A,B,C,D
Rationale: Fentanyl, an opioid, commonly causes nausea, constipation, pruritus, and urinary retention. Nystagmus is not a typical side effect.