Nokea
Physician's orders for a client with acute pancreatitis include the following: strict NPO and nasogastric tube to low intermittent suction. The nurse recognizes that witholding oral intake will:
- A. Reduce the secretion of pancreatic enzymes
- B. Decrease the client's need for insulin
- C. Prevent the secretion of gastric acid
- D. Eliminate the need for pain medication
Correct Answer: A
Rationale: Withholding oral intake (NPO) reduces stimulation of the pancreas, thereby decreasing the secretion of pancreatic enzymes that can exacerbate pancreatitis.
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The nurse recognizes that if eaten by a client, which food can alter results when stool is checked for occult blood?
- A. potatoes
- B. dairy products
- C. raw fruits
- D. beef
Correct Answer: D
Rationale: Beef contains heme, which can cause a false-positive result in a fecal occult blood test. Other foods listed do not typically interfere.
The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
- A. Place tape on the child's perianal area before putting the child to bed
- B. Scrape the skin with a piece of cardboard and bring it to the clinic
- C. Obtain a stool specimen in the afternoon
- D. Bring a hair sample to the clinic for evaluation
Correct Answer: A
Rationale: The tape test, applied to the perianal area at night or early morning, is the standard method to collect pinworm eggs.
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
- A. Be injected into the deltoid muscle
- B. Be injected into the abdomen
- C. Aspirate after the injection
- D. Clear the air from the syringe before injections
Correct Answer: B
Rationale: Lovenox is injected into the abdomen to ensure proper subcutaneous absorption and minimize bruising.
The physician has prescribed Chloromycetin (chloramphenicol) for a client with bacterial meningitis. Which lab report should the nurse monitor most carefully?
- A. Serum creatinine
- B. Urine specific gravity
- C. Complete blood count
- D. Serum sodium
Correct Answer: C
Rationale: Chloramphenicol can cause bone marrow suppression, so monitoring the complete blood count is critical.
The nurse is caring for a client who has stage 3 lung cancer and is in renal failure. The client indicates that he does not wish to have life-sustaining treatment and wants to die a natural death. What document does the nurse anticipate this client completing? Fill in the blank.
- A. Durable Power of Attorney for Healthcare
- B. Living Will
- C. Do Not Resuscitate Order
- D. Medical Power of Attorney
Correct Answer: B
Rationale: Living Will (B) is the correct answer, as it documents a client’s preferences for medical treatment, such as refusing life-sustaining measures, aligning with the client’s wish to die naturally without such interventions.