Nokea
The client is admitted to the medical floor with acute diverticulitis. Which collaborative intervention should the nurse anticipate the health-care provider ordering?
- A. Administer total parenteral nutrition.
- B. Maintain NPO and nasogastric tube.
- C. Maintain on a high-fiber diet and increase fluids.
- D. Obtain consent for abdominal surgery.
Correct Answer: B
Rationale: NPO status and an NG tube rest the bowel, reducing inflammation in acute diverticulitis. TPN is rare, high-fiber diets are for stable diverticulosis, and surgery is reserved for complications.
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The nurse, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task would be most appropriate to assign to the LPN?
- A. Assist the UAP to learn to perform blood glucose checks.
- B. Monitor the potassium levels of a client with diarrhea.
- C. Administer a bulk laxative to a client diagnosed with constipation.
- D. Assess the abdomen of a client who has had complaints of pain.
Correct Answer: C
Rationale: Administering a laxative is within the LPN’s scope. Teaching UAPs, monitoring labs, and abdominal assessments require RN skills.
The nurse identifies the client problem 'alteration in gastrointestinal system' for the elderly client. Which statement reflects the most appropriate rationale for this problem?
- A. Elderly clients have the ability to chew food more thoroughly with dentures.
- B. Elderly clients have an increase in digestive enzymes, which helps with digestion.
- C. Elderly clients have an increased need for laxatives because of a decrease in bile.
- D. Elderly clients have an increase in bacteria in the GI system, resulting in diarrhea.
Correct Answer: C
Rationale: Elderly clients often have reduced peristalsis and bile production, leading to constipation and increased laxative need, supporting the GI alteration problem. Dentures, enzyme increase, and bacterial overgrowth are less accurate.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.
The client is 6 days post—total proctocolectomy with ileostomy creation for ulcerative colitis. The client’s ileostomy is draining large amounts of liquid stool, and the client has dizziness with ambulation. Which parameters should the nurse assess immediately?
- A. Pulse rate for the last 24 hours
- B. Urine output for the last 24 hours
- C. Weight over the last 3 days
- D. Ability to move the lower extremities
- E. Temperature readings for the last 24 hours
Correct Answer: A, B, C, E
Rationale: The nurse should assess for increasing pulse rate over time because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. B. The nurse should assess for decreasing urine output because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. C. The nurse should assess for decreasing weight because it is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration. D. The ability to move the lower extremities is not related to dehydration. E. The nurse should assess the temperature readings because a low-grade temperature is a sign of dehydration; large amounts of ileostomy output can result in dehydration, and the dizziness with ambulation could be from dehydration.
A 32-year-old female is admitted for a hemorrhoidectomy. During the nursing assessment, all of the following factors are elicited. Which one is most likely to have contributed to the development of hemorrhoids?
- A. The client states that she usually cleans herself from back to front after a bowel movement.
- B. The client says her mother and grandmother had hemorrhoids.
- C. The client has had four pregnancies.
- D. The client eats bran every day.
Correct Answer: C
Rationale: Multiple pregnancies increase intra-abdominal pressure, a major risk factor for hemorrhoids. Family history may contribute, but pregnancies are more directly linked.