Nokea
The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first?
- A. Check for a fecal impaction.
- B. Encourage the client to drink fluids.
- C. Check the chart for sodium and potassium levels.
- D. Apply a protective barrier cream to the perianal area.
Correct Answer: D
Rationale: Dark, watery stool risks perianal skin breakdown, so applying a barrier cream is the first intervention. Impaction is unlikely, fluids are secondary, and labs follow assessment.
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Which blood test results would confirm a diagnosis of appendicitis?
- A. WBC of 13,000
- B. RBC of 4.5 million
- C. Platelet count of 300,000
- D. Positive heterophil antibody test
Correct Answer: A
Rationale: An elevated WBC count (e.g., 13,000) indicates inflammation, supporting an appendicitis diagnosis. Normal RBC and platelet counts are not specific, and a heterophil antibody test is for infectious mononucleosis.
The nurse is caring for the client with diverticulitis. The nurse should plan to instruct the client to avoid which food during an episode of diverticulitis?
- A. White bread
- B. Ripe banana
- C. Cooked oatmeal
- D. Iceberg lettuce
Correct Answer: C
Rationale: A. White bread is a recommended food for fiber-restricted diets. It contains less than 1 g fiber per ounce. B. Ripe bananas, canned soft fruits, and most well-cooked vegetables without seeds or skins are recommended for fiber-restricted diets. C. Cooked oatmeal contains 4 g of fiber per serving. Foods high in fiber should be avoided during an episode of diverticulitis, and foods should be restricted to low fiber or clear liquids. Once diverticulitis is resolved, the client should return to a high-fiber diet. D. Iceberg lettuce contains less than 1 g of fiber.
The nurse is preparing to administer 250 mL of intravenous antibiotic to the client. The medication must infuse in one (1) hour. An intravenous pump is not available and the nurse must administer the medication via gravity with IV tubing at 10 gtts/min. At what rate should the nurse infuse the medication?
Correct Answer: 42 gtts/min
Rationale: Volume = 250 mL, time = 60 min, drop factor = 10 gtts/mL. Drip rate = (250 × 10) ÷ 60 = 41.67, rounded to 42 gtts/min.
The nurse has been assigned to care for four clients. Which client should the nurse plan to assess first?
- A. The 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numerical scale
- B. The 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes
- C. The 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night
- D. The 54-year-old client with cirrhosis and jaundice who is reporting having itching all over the body
Correct Answer: B
Rationale: A. The client with a pain rating of 6 out of 10 on a numerical scale needs attention, but the pain is not a life-threatening concern. B. Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The nurse should assess this client first. C. The client who is postcholecystectomy is reported as being stable and could be assessed last. D. The client reporting itching needs attention, but the itching is not a life-threatening concern.
The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse?
- A. Raise the foot of the bed to 45 degrees to increase peristalsis.
- B. Eat the evening meal at least two (2) hours prior to bed.
- C. Eat a low-fat, low-cholesterol, high-fiber diet.
- D. Wear an abdominal binder to strengthen the abdominal muscles.
Correct Answer: B
Rationale: Eating at least two hours before bed prevents food pooling in the diverticula, reducing regurgitation risk. Raising the bed foot, specific diets, and binders are not standard.