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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The female client presents to the clinic for an examination because she has not had a menstrual cycle for several months and wonders if she could be pregnant. The client is 5'10 tall and weighs 45 kg. Which assessment data should the nurse obtain first?
- A. Ask the client to recall what she ate for the last 24 hours.
- B. Determine what type of birth control the client has been using.
- C. Reweigh the client to confirm the data.
- D. Take the client's pulse and blood pressure.
Correct Answer: D
Rationale: Low weight (BMI ~13.6) suggests anorexia, and vital signs (pulse, BP) assess for hemodynamic instability, a priority. Diet recall, birth control, and reweighing are secondary.
The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the nurse implement? Select all that apply.
- A. Place the client on a 72-hour calorie count.
- B. Ask the client to describe the stools.
- C. Have the UAP weigh the client.
- D. Obtain a list of current medications.
- E. Make a referral to the dietitian.
Correct Answer: A,C,D,E
Rationale: Calorie count, weight, medication list, and dietitian referral assess and manage malnutrition. Stool description is less relevant unless GI issues are present.
When an elderly client is receiving cimetidine [Tagamet], it is important that the nurse monitor for which side effect?
- A. Chest pain
- B. Confusion
- C. Dyspnea
- D. Urinary retention
Correct Answer: B
Rationale: Confusion is a potential side effect of cimetidine in elderly clients due to its central nervous system effects.
The nurse is discharging the client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, which information should the nurse include in the client’s discharge instructions?
- A. Drink plenty of fluids with all your meals.
- B. Eat a high-carbohydrate, low-protein diet
- C. Wait to eat at least 5 hours between meals.
- D. Lie down for 20 to 30 minutes after meals.
Correct Answer: D
Rationale: A. Drinking fluids at mealtime increases the size of the food bolus that enters the stomach. B. Carbohydrates are more rapidly digested than fats and proteins and would cause the food bolus to pass quickly into the intestine, increasing the likelihood that dumping syndrome would occur. Meals high in carbohydrates result in postprandial hypoglycemia, which is considered a variant of dumping syndrome. C. Small, frequent meals are recommended to decrease dumping syndrome. D. Lying down after meals slows the passage of the food bolus into the intestine and helps to control dumping syndrome.
A client had a barium enema. Following the barium enema, the nurse should anticipate an order for which of the following?
- A. An antacid
- B. A laxative
- C. A muscle relaxant
- D. A sedative
Correct Answer: B
Rationale: Barium is constipating, and a laxative is typically ordered to prevent bowel obstruction post-barium enema.