Nokea
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Need for the client to increase fluid intake to 3000 mL/day
- B. Follow-up visits every 3 weeks for the first 6 months
- C. B12 injections needed for the rest of the client's life
- D. Need to eat three full meals with plenty of fiber per day
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
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The nurse is caring for a client with a history of cirrhosis. Which dietary restriction is most important?
- A. Low fat
- B. Low protein
- C. Low sodium
- D. Low carbohydrate
Correct Answer: C
Rationale: Low sodium is critical in cirrhosis to reduce fluid retention and ascites caused by portal hypertension and hypoalbuminemia. Protein is moderated but not severely restricted, and fat and carbohydrates are less critical.
A client is being evaluated for carpal tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel’s sign involves tapping the median nerve to elicit pain/tingling in carpal tunnel syndrome. Phalen’s maneuver (A) involves wrist flexion, Kernig’s (C) and Brudzinski’s (D) are for meningitis.
A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:
- A. Take the medication with juice
- B. Expect red discoloration of the urine
- C. Take the medication before going to bed at night
- D. Take the medication only if night sweats occur
Correct Answer: B
Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.
A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?
- A. The nurse lowers the temperature of the room.
- B. The nurse places an airway at the bedside.
- C. The nurse inserts an indwelling catheter and obtains an hourly intake and output.
- D. The nurse darkens the room to reduce environmental stimuli.
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Explain what will take place and what she will see, feel, and hear.
- B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
Correct Answer: A
Rationale: Providing a detailed explanation of the procedure helps reduce anxiety by preparing the child for what to expect, addressing her previous experience.