Nokea
The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
- A. Avoid rectal temperatures.
- B. Use only a soft toothbrush.
- C. Monitor the platelet count.
- D. Use small-gauge needles.
- E. Assess for asterixis.
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.
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Which information should the nurse teach the client post-barium enema procedure?
- A. The client should not eat or drink anything for four (4) hours.
- B. The client should remain on bedrest until the sedative wears off.
- C. The client should take a mild laxative to help expel the barium.
- D. The client will have normal elimination color and pattern.
Correct Answer: C
Rationale: A mild laxative helps expel barium, preventing constipation or impaction post-barium enema. NPO, bedrest, and normal stool color are incorrect.
Which instruction should the nurse discuss with the client who is in the icteric phase of hepatitis C?
- A. Decrease alcohol intake.
- B. Encourage rest periods.
- C. Eat a large evening meal.
- D. Drink diet drinks and juices.
Correct Answer: B
Rationale: Rest periods conserve energy and support recovery during the icteric phase of hepatitis C, when jaundice and fatigue are prominent. Alcohol avoidance is general advice, and diet changes are less specific.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.
The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid.
- B. Encourage the client to ventilate feelings about body image.
- C. Administer opioid narcotic medications for pain management.
- D. Assist the client out of bed to sit in the chair twice daily.
Correct Answer: B
Rationale: Encouraging ventilation of feelings about body image is an independent nursing intervention addressing psychosocial needs post-colostomy. IV rate, opioids, and ambulation require orders or are less psychosocial.
Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.