Nokea
Following a hemorrhoidectomy, the nurse assesses the client's voiding. What is the reason for this concern?
- A. The client has been NPO before and during surgery.
- B. Urinary retention is frequently seen after a hemorrhoidectomy.
- C. The client has a long history of hemorrhoids, making her prone to voiding problems.
- D. The client had several pregnancies, which can make voiding difficult.
Correct Answer: B
Rationale: Urinary retention is common post-hemorrhoidectomy due to pain and swelling affecting pelvic nerves.
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The nurse is caring for a client diagnosed with bulimia nervosa. Which nursing intervention should the nurse implement after the client's evening meal?
- A. Praise the client for eating all the food on the tray.
- B. Stay with the client for 45 minutes to an hour.
- C. Allow the client to work out on the treadmill.
- D. Place the client on bedrest until morning.
Correct Answer: B
Rationale: Staying with the client prevents purging, a key behavior in bulimia, post-meal. Praising eating, exercise, or bedrest does not address purging.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?
- A. Tell the client to measure the amount of stool.
- B. Recommend the client come to the clinic immediately.
- C. Explain the client should follow the BRAT diet.
- D. Discuss taking an over-the-counter histamine-2 blocker.
Correct Answer: C
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is bland and helps manage diarrhea. Measuring stool is impractical, immediate clinic visits depend on severity, and H2 blockers are irrelevant.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.
The nurse is preparing a client with Crohn's disease for discharge. Which of the following statements indicates that he needs further teaching?
- A. Stress can make it worse.'
- B. Since I have Crohn's disease, I don't have to worry about colon cancer.'
- C. I realize I shall always have to monitor my diet.'
- D. I understand there is a high incidence of familial occurrence with this disease.'
Correct Answer: B
Rationale: Crohn’s disease increases the risk of colon cancer, so the statement indicates a need for further teaching. The other statements are correct.