Nokea
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- A. Constipation
- B. Hyperphosphatemia
- C. Hypomagnesemia
- D. Diarrhea
Correct Answer: A
Rationale: Calcium carbonate can cause constipation, a common side effect, due to its effect on gastrointestinal motility.
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A nurse is caring for a client who has just undergone an ileostomy procedure. The nurse expects how much drainage from the ileostomy during the first 24 hours post-op?
- A. 650 mL
- B. 800 mL
- C. 1,500 mL
- D. 3,500 mL
Correct Answer: B
Rationale: Ileostomy drainage in the first 24 hours post-op is typically 500-1,000 mL due to liquid stool output. 800 mL is the most reasonable estimate.
A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?
- A. Roast beef
- B. Broiled fish
- C. Baked chicken
- D. Sliced pork
Correct Answer: D
Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.
The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.
- A. Palpate vein.
- B. Cleanse skin
- C. Apply tourniquet.
- D. Perform venipuncture.
Correct Answer: C,A,B,D
Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Fluid volume deficit is a priority in ulcerative colitis due to frequent diarrhea, which can lead to dehydration.
A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
- A. Disturbed body image related to major changes in the structure and function of the larynx
- B. Ineffective airway clearance related to excess mucus in airway, due to surgical procedure
- C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
- D. Impaired verbal communication related to inability to talk, due to removal of larynx
Correct Answer: B
Rationale: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.