Nokea
A postpartum client who experienced a perineal laceration reports pain and discomfort during defecation. What nursing intervention should be prioritized to alleviate symptoms?
- A. Recommending the use of stool softeners or laxatives
- B. Encouraging the client to increase fluid and fiber intake
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper positioning for defecation
Correct Answer: A
Rationale: The priority nursing intervention for a postpartum client who experienced a perineal laceration and reports pain and discomfort during defecation is to recommend the use of stool softeners or laxatives. Perineal lacerations can lead to pain and discomfort during bowel movements due to the strain that passing stools may cause on the tender area. Stool softeners or laxatives can help soften the stool, making it easier and less painful for the client to have bowel movements. It is important to alleviate the discomfort and promote bowel regularity to prevent complications such as constipation, which can further exacerbate the pain and delay healing of the perineal laceration.
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Which of the following screening tests is recommended for cervical cancer prevention in women aged 21 to 65 years?
- A. Human papillomavirus (HPV) testing alone
- B. Cytology (Pap smear) alone
- C. Co-testing with cytology and HPV testing
- D. Endometrial biopsy
Correct Answer: B
Rationale: The recommended screening test for cervical cancer prevention in women aged 21 to 65 years is cytology, also known as a Pap smear. The Pap smear is a test that looks for changes in the cells of the cervix that could indicate the presence of cervical cancer or pre-cancerous conditions. This test is recommended every 3 years for women aged 21-29 years, and every 3-5 years for women aged 30-65 years, depending on the screening method used. HPV testing alone or co-testing with both cytology and HPV testing may be used in certain situations, but for most women in this age group, cytology (Pap smear) alone is the recommended screening test.
A patient is prescribed a proton pump inhibitor (PPI) for the treatment of peptic ulcer disease. Which adverse effect should the nurse monitor closely in the patient?
- A. Constipation
- B. Hypokalemia
- C. Diarrhea
- D. Clostridium difficile infection
Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) are commonly prescribed for conditions involving excessive stomach acid production, such as peptic ulcer disease. One of the potential adverse effects of PPIs, such as omeprazole or pantoprazole, is the risk of hypokalemia. Hypokalemia is a condition characterized by low levels of potassium in the bloodstream. Prolonged use of PPIs can inhibit the absorption of potassium in the intestines, leading to a decrease in potassium levels in the body. Hypokalemia can present with symptoms such as muscle weakness, fatigue, irregular heartbeat, and in severe cases, it can result in life-threatening complications like cardiac arrhythmias. Therefore, it is essential for the nurse to closely monitor the patient for signs and symptoms of hypokalemia while on PPI therapy, especially if the patient is at risk for developing electrolyte imbalances.
Which of the following study designs that uses information on current health status, personal characteristics, and potential risk factors will be appropriate?
- A. Case-control
- B. Cohort
- C. Ecological
- D. Cross-sectional
Correct Answer: B
Rationale: A cohort study design would be appropriate in this scenario. Cohort studies follow a group of individuals over a period of time to assess how their current health status, personal characteristics, and potential risk factors may contribute to the development of certain outcomes or diseases. By collecting data at different time points on the same group of individuals, cohort studies allow researchers to establish associations between exposures and outcomes, providing valuable information on causality. In this case, using a cohort study design would allow for a comprehensive examination of how various factors impact health outcomes over time.
A patient with a history of myocardial infarction is prescribed atorvastatin for lipid-lowering therapy. Which parameter should the nurse monitor closely during atorvastatin therapy?
- A. Serum potassium levels
- B. Liver function tests
- C. Blood glucose levels
- D. Serum sodium levels
Correct Answer: B
Rationale: Atorvastatin is a medication commonly used for lipid-lowering therapy to reduce cholesterol levels and decrease the risk of cardiovascular events. However, one of the potential side effects of statin medications such as atorvastatin is liver injury. Therefore, monitoring liver function tests, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, is crucial during atorvastatin therapy.
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.