Nokea
Following a hemorrhoidectomy, the nurse is instructing the client in self-care. Which statement is especially important to include in these instructions?
- A. Wash the anal area with water after defecation and pat it dry.'
- B. Gently wipe the anal area after defecation from back to front.'
- C. Do not drink more than three glasses of fluid per day until after you have had the first bowel movement.'
- D. When you first feel the need to defecate, call me and I will give you the enema the doctor has ordered.'
Correct Answer: A
Rationale: Washing and patting dry promotes hygiene and healing post-hemorrhoidectomy, reducing irritation.
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Which diagnostic data should be reported to the health-care provider (HCP) immediately?
- A. The ABG result of pH 7.11, PaCO2 45, HCO3 20, and PaO2 98 for a client diagnosed with type 1 diabetes.
- B. Sodium 137 mEq/L, potassium 4 mEq/L, glucose 120 mg/dL for a client diagnosed with gastroenteritis.
- C. Hemoglobin 9.4 g/dL and hematocrit 29% for a client who received a blood transfusion on the previous shift.
- D. A pulse oximetry reading of 93% for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Correct Answer: A
Rationale: A pH of 7.11 indicates severe acidosis (likely DKA in type 1 diabetes), requiring immediate HCP notification. Normal electrolytes, post-transfusion anemia, and COPD oximetry are less urgent.
The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first?
- A. Check for a fecal impaction.
- B. Encourage the client to drink fluids.
- C. Check the chart for sodium and potassium levels.
- D. Apply a protective barrier cream to the perianal area.
Correct Answer: D
Rationale: Dark, watery stool risks perianal skin breakdown, so applying a barrier cream is the first intervention. Impaction is unlikely, fluids are secondary, and labs follow assessment.
Warm oatmeal (Aveeno) baths are ordered for a client with cancer of the pancreas. What is the chief purpose of this procedure for this client?
- A. Relief of paralytic ileus
- B. Alleviation of pruritus associated with jaundice
- C. Relief of bloating and fullness after eating
- D. Reducing the fever associated with the disease
Correct Answer: B
Rationale: Oatmeal baths alleviate pruritus caused by jaundice, a common symptom in pancreatic cancer due to bile salt accumulation.
The client with hepatitis asks the nurse, 'I went to an herbalist, who recommended I take milk thistle. What do you think about the herb?' Which statement is the nurse's best response?
- A. You are concerned about taking an herb.
- B. The herb has been used to treat liver disease.
- C. I would not take anything that is not prescribed.
- D. Why would you want to take any herbs?
Correct Answer: B
Rationale: Milk thistle is commonly used for liver support and may have hepatoprotective effects, though evidence is limited. This response provides accurate information without dismissing the client’s query.
The client who has had an abdominal perineal resection is being discharged. Which discharge information should the nurse teach?
- A. The stoma should be a white, blue, or purple color.
- B. Limit ambulation to prevent the pouch from coming off.
- C. Take pain medication when the pain level is at an '8.'
- D. Empty the pouch when it is one-third to one-half full.
Correct Answer: D
Rationale: Emptying the pouch when one-third to one-half full prevents leaks and skin irritation. A healthy stoma is pink/moist, ambulation is encouraged, and pain medication should be taken before pain becomes severe.