Nokea
In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful?
- A. Number and length of breaks.
- B. Body mechanics used in lifting.
- C. Temperature in the work area.
- D. Cleaning solvents used.
Correct Answer: B
Rationale: Poor body mechanics during lifting can increase intra-abdominal pressure, exacerbating hiatal hernia symptoms, making this the most relevant work-related factor.
You may also like to solve these questions
At 8 a.m., the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
- A. Report the 24-hour drainage amount at 12. Clamp the T-tube.
- B. Evaluate the tube for patency.
- C. Irrigate the T-tube.
- D. Continue to monitor the drainage.
Correct Answer: C
Rationale: The T-tube should drain approximately 300 to 500 mL in the fi rst 24 hours and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 8 a.m., the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without an order.
The nurse is preparing a client for a paracentesis. The nurse should:
- A. Have the client void immediately before the procedure.
- B. Place the client in a side-lying position.
- C. Initiate an I.V. line to administer sedatives.
- D. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
Correct Answer: A
Rationale: Voiding before paracentesis (A) prevents bladder injury during the procedure. Side-lying (B) is incorrect; upright is preferred. IV sedatives (C) are not routine, and NPO status (D) is unnecessary.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
- A. The client verbalizes the understanding that his physical activity must be curtailed.
- B. The client states that he will place an aspirin in the drainage pouch to help control odor.
- C. The client demonstrates how to catheterize the stoma.
- D. The client states that he will empty the drainage pouch frequently throughout the day.
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.
A family member asks the nurse why their loved one with end-stage liver cancer is so restless. The nurse's best response is:
- A. Restlessness is a side effect of pain medications.
- B. It may be due to decreased oxygen to the brain.
- C. It's a normal part of the dying process.
- D. It's caused by dehydration.
Correct Answer: C
Rationale: Restlessness is a common symptom in the dying process, often due to metabolic changes or psychological factors, and explaining this normalizes the family's experience.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis. High-protein (B) may worsen encephalopathy. Low-fat, low-protein (C) is too restrictive. Low-sodium (D) is relevant for ascites, not early cirrhosis.