Nokea
The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective?
- A. I will have four (4) to five (5) small incisions.
- B. I will be in the hospital for at least one (1) week.
- C. I will not have any pain because this is laparoscopic surgery.
- D. I will be returning to work the day after my surgery.
Correct Answer: A
Rationale: Laparoscopic Nissen fundoplication involves 4–5 small incisions, indicating effective teaching. Hospital stays are shorter, pain is expected, and return to work takes longer.
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The 22-year-old female who is obese is discussing weight loss programs with the nurse. Which information should the nurse teach?
- A. Jog for two (2) to three (3) hours every day.
- B. Lifestyle behaviors must be modified.
- C. Eat one (1) large meal every day in the evening.
- D. Eat 1,000 calories a day and don't take vitamins.
Correct Answer: B
Rationale: Modifying lifestyle behaviors (e.g., diet, exercise, habits) is essential for sustainable weight loss. Excessive jogging, one large meal, or extreme calorie restriction are unsafe.
The client is admitted with upper right-side abdominal pain. The nurse is concerned that the client may have liver cancer when which serum laboratory test results are elevated?
- A. Creatinine and BUN
- B. α-fetoprotein (AFP)
- C. Phosphorus levels
- D. CA-125 levels
Correct Answer: B
Rationale: A. Elevated serum creatinine and BUN are associated with renal problems. B. Serum α-fetoprotein is a major serum protein synthesized by fetal liver cells, by yolk sac cells, and in small amounts by the fetal GI system. Reappearance of AFP in adults signals pathological problems. In 50% to 75% of clients with liver cancer, serum AFP levels are elevated. C. Elevated serum phosphorus is associated with renal and many other diseases and is not specific to liver cancer. D. CA-125 is a tumor marker for ovarian cancer.
The client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client?
- A. Explain some blood in the stool will be normal for the client.
- B. Instruct the client in manual removal of feces.
- C. Encourage the client to use a cathartic laxative on a daily basis.
- D. Place the client on a high-fiber diet.
Correct Answer: D
Rationale: A high-fiber diet promotes regular, softer stools, reducing straining. Blood is not normal, manual removal is invasive, and daily laxatives cause dependency.
The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.
The nurse is caring for the client with Clostridium difficile. Which intervention should the nurse implement to prevent health-care associated infection (HAl) spread to other clients?
- A. Wash hands with Betadine for two (2) minutes after giving care.
- B. Wear nonsterile gloves when handling GI excretions.
- C. Clean the perianal area with soap and water after each stool.
- D. Flush the commode twice when disposing of stool.
Correct Answer: C
Rationale: Cleaning the perianal area with soap and water after each stool reduces the risk of Clostridium difficile spore transmission, which is critical for preventing healthcare-associated infections. Betadine is not standard, gloves are insufficient alone, and flushing twice is not evidence-based.