Nokea
The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care?
- A. Administer a laxative of choice.
- B. Encourage the client to increase oral fluids.
- C. Encourage the client to take deep breaths.
- D. Maintain a patent nasogastric tube.
Correct Answer: D
Rationale: Maintaining a patent NG tube decompresses the bowel in paralytic ileus, preventing complications. Laxatives and oral fluids are contraindicated, and deep breathing is unrelated.
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The clinic nurse is returning client calls. Which client should the nurse call first?
- A. The 39-year-old client complaining of headache pain with a 3 on the pain scale.
- B. The 45-year-old client who needs a prescription refill for warfarin.
- C. The 54-year-old client diagnosed with diabetes type 1 who has been vomiting.
- D. The 60-year-old client who cannot afford to buy food and needs assistance.
Correct Answer: C
Rationale: Vomiting in a type 1 diabetic risks diabetic ketoacidosis, a medical emergency, requiring immediate attention. Headache, warfarin refill, and food insecurity are less urgent.
The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement?
- A. Weigh the client daily and document in the client's chart.
- B. Teach coping strategies such as dietary modifications.
- C. Record the frequency, amount, and color of stools.
- D. Monitor the client's oral fluid intake every shift.
Correct Answer: C
Rationale: Recording stool frequency, amount, and color is critical in acute IBD exacerbation to assess disease activity and guide treatment. Weight and fluid monitoring are important but secondary, and teaching is less urgent during an acute phase.
The client is admitted with end-stage liver failure and is prescribed the laxative lactulose (Chronulac). Which statement indicates the client needs more teaching concerning this medication?
- A. I should have two to three soft stools a day.
- B. I must check my ammonia level daily.
- C. If I have diarrhea, I will call my doctor.
- D. I should check my stool for any blood.
Correct Answer: B
Rationale: Clients do not routinely check ammonia levels at home; this is done clinically if needed. The other statements reflect correct understanding of lactulose use for hepatic encephalopathy.
The nurse is caring for the client diagnosed with ascites secondary to hepatic cirrhosis. Which information should the nurse report to the health-care provider?
- A. A decrease in the client's daily weight of one (1) pound.
- B. An increase in urine output after administration of a diuretic.
- C. An increase in abdominal girth of two (2) inches.
- D. A decrease in the serum direct bilirubin to 0.6 mg/dL.
Correct Answer: C
Rationale: An increase in abdominal girth (2 inches) suggests worsening ascites, requiring HCP notification. Weight loss, increased urine output, and normal bilirubin are expected or less urgent.
The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?
- A. Start auscultating to the left of the umbilicus.
- B. Turn off the NG suction before auscultation.
- C. Use the bell of the stethoscope for auscultation.
- D. Empty the drainage canister before auscultation.
Correct Answer: B
Rationale: A. When the client has hypoactive bowel sounds, which would be expected in a postsurgical client, the nurse should begin listening over the ileocecal valve in the right lower abdominal quadrant rather than to the left of the umbilicus. The ileocecal valve normally is a very active area. B. When listening for bowel sounds on the client who has an NG tube to suction, the nurse should turn off the suction during auscultation to prevent mistaking the suction sound for bowel sounds. C. The diaphragm of the stethoscope should be utilized for bowel sounds. The bell of the stethoscope should be utilized for abdominal vascular sounds, such as bruits. D. There is no reason to empty the canister before auscultation.