Nokea
The client at the eating disorder clinic weighs 35 kg and is 5 ft 7 inches tall. Which would the nurse document as the Body Mass Index (BMI)?
Correct Answer: 11.5
Rationale: BMI = weight (kg) / height (m)^2. Height = 5'7 = 1.73 m. BMI = 35 / (1.73)^2 = 35 / 2.9929 ≈ 11.5.
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The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.
The client two (2) hours postoperative laparoscopic cholecystectomy is complaining of severe pain in the right shoulder. Which nursing intervention should the nurse implement?
- A. Apply a heating pad to the abdomen for 15 to 20 minutes.
- B. Administer morphine sulfate intravenously after diluting with saline.
- C. Contact the surgeon for an order to x-ray the right shoulder.
- D. Apply a sling to the right arm, which was injured during surgery.
Correct Answer: B
Rationale: Right shoulder pain post-laparoscopic cholecystectomy is often referred pain from CO2 used in the procedure irritating the diaphragm. IV morphine relieves pain effectively. Heating pads, x-rays, or slings are inappropriate.
The client is one (1) hour post-endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse include in the plan of care?
- A. Instruct the client to cough forcefully.
- B. Encourage early ambulation.
- C. Assess for return of a gag reflex.
- D. Administer held medications.
Correct Answer: C
Rationale: ERCP involves throat anesthesia, so assessing the gag reflex ensures safe swallowing post-procedure. Coughing, ambulation, and medications are secondary.
The client has an eviscerated abdominal wound. Which intervention should the nurse implement?
- A. Apply sterile normal saline dressing.
- B. Use sterile gloves to replace protruding parts.
- C. Place the client in reverse Trendelenburg position.
- D. Administer intravenous antibiotic immediately (STAT).
Correct Answer: A
Rationale: Applying a sterile normal saline dressing keeps the eviscerated wound moist and protected until surgical repair. Replacing organs is contraindicated, reverse Trendelenburg is incorrect, and antibiotics are secondary.
The nurse caring for a client one (1) day postoperative sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention should the nurse implement first?
- A. Mark the drainage on the dressing with the time and date.
- B. Change the dressing immediately using sterile technique.
- C. Notify the health-care provider immediately.
- D. Reinforce the dressing with a sterile gauze pad.
Correct Answer: C
Rationale: Dark reddish brown drainage one day post-surgery suggests possible bleeding or dehiscence, warranting immediate notification of the HCP for evaluation. Marking or reinforcing the dressing delays action, and changing the dressing is secondary.