Nokea
The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that
- A. This indicates inadequate preoperative bowel preparation.
- B. This is a normal, expected event.
- C. The client is experiencing early signs of ischemic bowel.
- D. The client should not have the nasogastric tube removed.
Correct Answer: B
Rationale: The correct answer is B: This is a normal, expected event. After colostomy creation, it is common for clients to pass malodorous flatus from the stoma as the intestines begin to function. This is due to the presence of normal intestinal flora. Choice A is incorrect as preoperative bowel preparation does not directly relate to malodorous flatus post-colostomy. Choice C is incorrect as ischemic bowel presents with more serious symptoms. Choice D is incorrect as nasogastric tube removal is not related to passing flatus from the stoma.
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A nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of
- A. 45 units/L
- B. 100 units/L
- C. 300 units/L
- D. 500 units/L
Correct Answer: C
Rationale: The correct answer is C (300 units/L) because in chronic pancreatitis, there is ongoing inflammation and damage to the pancreas, leading to elevated serum amylase levels. A level of 300 units/L is indicative of pancreatitis. Choices A and B are too low for chronic pancreatitis, and choice D is too high and would typically be seen in acute pancreatitis.
Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
- A. verbalize absence of epigastric pain.
- B. accept the need to inject himself with vitamin B12 for the rest of his life.
- C. understand the need to increase his exercise activity.
- D. eliminate stress from his life.
Correct Answer: A
Rationale: The correct answer is A: verbalize absence of epigastric pain. This outcome is most appropriate as it directly relates to the client's condition of peptic ulcer disease. Verbalizing the absence of epigastric pain indicates that the client's ulcer is healing and symptoms are improving. It is a measurable and specific goal that reflects the client's progress in managing the disease.
Choice B is incorrect as vitamin B12 injections are not typically necessary for peptic ulcer disease. Choice C is incorrect as exercise may not directly impact the ulcer and may even exacerbate symptoms. Choice D is incorrect as eliminating stress completely is unrealistic and may not directly impact the ulcer.
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.
The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to
- A. Eat a good supper when anorexia is not as severe.
- B. Eat less often, preferably only three large meals daily.
- C. Increase intake of fluids including juices.
- D. Select foods high in fat.
Correct Answer: C
Rationale: The correct answer is C: Increase intake of fluids including juices. This is because viral hepatitis can cause anorexia and a decreased taste for food, leading to poor nutrition. Increasing fluid intake, especially juices, can help provide essential nutrients and prevent dehydration.
A: Eating a good supper when anorexia is not as severe may not be effective in addressing the client's overall nutritional needs during the day.
B: Eating less often and only three large meals daily can worsen the client's nutritional status and may not address the decreased appetite and taste for food.
D: Selecting foods high in fat may not be appropriate for someone with viral hepatitis, as it can exacerbate liver inflammation and contribute to poor nutrition.
The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
- A. Continuing to advance the tube to the desired distance
- B. Pulling the tube back slightly
- C. Checking the back of the pharynx using a tongue blade and flashlight.
- D. Instructing the client to breathe slowly and take sips of water.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. The client is experiencing coughing, gagging, and choking, indicating improper tube insertion.
2. Continuing to advance the tube can lead to further discomfort and potential complications.
3. Pulling the tube back slightly allows for reevaluation of placement and prevents further irritation.
4. Checking the back of the pharynx can identify any obstruction or incorrect placement.
5. Instructing the client to breathe slowly and take sips of water can help relax the client and facilitate proper insertion.