Nokea
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.
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The charge nurse is making assignments. Staffing includes a registered nurse with five (5) years of medical-surgical experience, a newly graduated registered nurse, and two (2) unlicensed assistive personnel (UAPs). Which client should be assigned to the most experienced nurse?
- A. The 39-year-old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis.
- B. The 54-year-old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning.
- C. The 46-year-old client diagnosed with gastroesophageal reflux disease who has wheezes in all five (5) lobes.
- D. The 68-year-old client who is three (3) days postoperative for hiatal hernia and needs to be ambulated four (4) times today.
Correct Answer: C
Rationale: The client with GERD and wheezing in all five lobes indicates potential respiratory complications, possibly asthma or aspiration, requiring complex assessment and management best suited for the experienced nurse. The other clients have less acute or complex needs.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the client’s intake and output.
- B. Take the client’s vital signs.
- C. Change the client’s intravenous solution.
- D. Assess the client’s perianal area.
Correct Answer: B
Rationale: Taking vital signs is within the UAP’s scope and supports monitoring in gastroenteritis. Evaluating intake/output, changing IV solutions, and assessing skin require RN skills.
The nurse is caring for the client diagnosed with hepatic encephalopathy. Which sign and symptom indicate the disease is progressing?
- A. The client has a decrease in serum ammonia level.
- B. The client is not able to circle choices on the menu.
- C. The client is able to take deep breaths as directed.
- D. The client is able to eat previously restricted food items.
Correct Answer: B
Rationale: Inability to circle menu choices indicates worsening cognitive function, a sign of progressing hepatic encephalopathy. Decreased ammonia, following directions, and eating are positive or unrelated.
The client is prescribed infliximab 5 mg/kg every 8 weeks for treatment of Crohn’s disease. The client weighs 116 lb. How many milligrams (mg) should the nurse administer? _________ mg (Record your answer rounded to a whole number.)
Correct Answer: 264
Rationale: To calculate the dose: 1. Convert weight to kilograms: 116 lb ÷ 2.2 = 52.727 kg. 2. Calculate dose: 5 mg/kg × 52.727 kg = 263.635 mg. 3. Round to a whole number: 264 mg.
The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and T 102°F. Which intervention should the nurse implement?
- A. Notify the health-care provider.
- B. Prepare to administer a Fleet's enema.
- C. Administer an antipyretic suppository.
- D. Continue to monitor the client closely.
Correct Answer: A
Rationale: A rigid abdomen and fever (102°F) suggest possible perforation or peritonitis, requiring immediate HCP notification for evaluation and possible surgical intervention. Enemas are contraindicated, and antipyretics or monitoring delay critical action.