Nokea
A client with a perforated bowel secondary to a bowel obstruction.
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
- A. Maintain the client in a supine position.
- B. Notify the client's next-of-kin.
- C. Prepare the client for emergency surgery.
- D. Remove the nasogastric tube.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
You may also like to solve these questions
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?
- A. Name the year. What season is this?
- B. Subtract 7 from 100 and then subtract 7 from that. Now continue to subtract 7 from the new number.
- C. I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.
- D. What is this on my wrist? Then ask, What is the purpose of it?
Correct Answer: C
Rationale: I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen. This tests immediate recall, a component of recent memory.
An adult male calls his nurse neighbor and says he is having severe chest pain and feels as though something terrible is happening to him. He rates his pain as 10 on the 10-point scale. In addition to calling 911, what should the nurse recommend the man do now?
- A. Take an aspirin
- B. Lie flat
- C. Take some deep breaths
- D. Go to bed
Correct Answer: A
Rationale: Aspirin reduces clot formation in suspected myocardial infarction, improving outcomes, and should be taken immediately.
A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
- A. Diminished breath sounds on the right
- B. Left-sided tracheal deviation
- C. Right-sided tracheal deviation
- D. Presence of bilateral ronchi
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
- A. Increases the cardiac output
- B. Decreases the cardiac output
- C. Indicates a cardiac tamponade
- D. Increases diaphoresis and the likelihood of hypothermia
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma