Nokea
The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.
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The client diagnosed with end-stage liver failure is admitted with esophageal bleeding. The HCP inserts and inflates a triple-lumen nasogastric tube (Sengstaken-Blakemore). Which nursing intervention should the nurse implement for this treatment?
- A. Assess the gag reflex every shift.
- B. Stay with the client at all times.
- C. Administer the laxative lactulose (Chronulac).
- D. Monitor the client's ammonia level.
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can dislodge or cause complications like aspiration, requiring constant monitoring. Gag reflex, lactulose, and ammonia are unrelated to this intervention.
During a home visit, the client’s spouse reports that since her husband’s placement of a colostomy 3 months ago, he has lost interest in golf. She also says he cries often for no reason, sleeps for only a few hours at night, and reports fatigue. The wife asks the nurse for advice. Which statement should be the basis for the nurse’s response?
- A. One in four clients develops depression after ostomy surgery.
- B. Athletic activities like golf are not possible after ostomy surgery.
- C. After 3 months the client should have accepted his new body image.
- D. The smell and location make it difficult to sleep well with an ostomy.
Correct Answer: A
Rationale: The client is exhibiting signs of depression. At least 25% of clients develop clinically significant depression following colostomy. Poor adjustment to a stoma correlates to development of depression.
The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers?
- A. Do not allow students to eat or drink after each other.
- B. Drink bottled water as much as possible.
- C. Encourage protected sexual activity.
- D. Sing the happy birthday song while washing hands.
Correct Answer: D
Rationale: Handwashing (e.g., for the duration of singing 'Happy Birthday') is the most effective way to prevent fecal-oral transmission of hepatitis A in a school setting. Sharing food/drink is a risk but less critical than hygiene.
The nurse has received the a.m. shift report. Which client should the nurse assess first?
- A. The 44-year-old client diagnosed with peptic ulcer disease who is complaining of acute epigastric pain.
- B. The 74-year-old client diagnosed with acute gastroenteritis who has had four (4) diarrhea stools during the night.
- C. The 65-year-old client diagnosed with IBD who has tented skin turgor and dry mucous membranes.
- D. The 15-year-old client diagnosed with food poisoning who has vomited several times during the night shift.
Correct Answer: C
Rationale: Tented skin turgor and dry mucous membranes in an elderly IBD patient indicate severe dehydration, a life-threatening condition requiring immediate assessment. Other clients have concerning but less urgent symptoms.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.