Nokea
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?
- A. Notify the surgeon of the client's status.
- B. Continue giving enemas until clear.
- C. Increase the client's IV fluid rate.
- D. Obtain STAT serum electrolytes.
Correct Answer: A
Rationale: Notifying the surgeon ensures guidance on proceeding, as unclear returns may indicate obstruction or inadequate prep, risking complications. More enemas, IV fluids, or electrolytes are secondary.
You may also like to solve these questions
Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle?
- A. Alteration in skin integrity.
- B. Knowledge deficit of postoperative care.
- C. Alteration in gas exchange and pattern.
- D. Alteration in urinary elimination.
Correct Answer: B
Rationale: Knowledge deficit of postoperative care (e.g., weight-bearing, wound care) is common pre-ankle surgery, guiding teaching. Skin integrity, gas exchange, and urinary issues are postoperative or unrelated.
Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain?
- A. Ineffective coping.
- B. Potential for injury.
- C. Alteration in comfort.
- D. Altered sensory input.
Correct Answer: C
Rationale: Alteration in comfort directly addresses acute pain’s impact, per NANDA-I. Coping, injury, and sensory input are secondary or unrelated.
Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective?
- A. I will take my temperature each week and report any elevation.
- B. I will not need any pain medication when I go home.
- C. I will take all of my antibiotics until they are gone.
- D. I will not take a shower until my three (3)-month checkup.
Correct Answer: C
Rationale: Completing antibiotics prevents infection, a key teaching point. Weekly temperature checks are excessive, pain medication is often needed, and showering is allowed sooner.
Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery?
- A. Alteration in comfort.
- B. Disuse syndrome.
- C. Risk for injury.
- D. Altered gas exchange.
Correct Answer: C
Rationale: Risk for injury (e.g., from positioning, equipment) is a primary intraoperative concern, per NANDA-I. Comfort, disuse, and gas exchange are more postoperative or anesthesia-related.