Nokea
Claire, a 33 y.o. is on your floor with a possible bowel obstruction. Which intervention is priority for her?
- A. Obtain daily weights.
- B. Measure abdominal girth.
- C. Keep strict intake and output.
- D. Encourage her to increase fluids.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct Answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
Matt is a 49 y.o. with a hiatal hernia that you are about to counsel. Health care counseling for Matt should include which of the following instructions?
- A. Restrict intake of high-carbohydrate foods.
- B. Increase fluid intake with meals.
- C. Increase fat intake.
- D. Eat three regular meals a day.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client's bowel sounds
- B. administration of pain medication every 4 hours
- C. Evaluating the client's response to antidiarrheal medications
- D. Maintaining intake and output records
Correct Answer: D
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
Arthur has a family history of colon cancer and is scheduled to have a sigmoidoscopy. He is crying as he tells you, "I know that I have colon cancer, too." Which response is most therapeutic?
- A. I know just how you feel.
- B. You seem upset.
- C. Oh, don't worry about it, everything will be just fine.
- D. Why do you think you have cancer?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You're developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?
- A. Omit fluids with meals.
- B. Increase carbohydrate intake.
- C. Decrease protein intake.
- D. Decrease fat intake.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.