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The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.
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The nurse is caring for the client with hepatic encephalopathy who is receiving lactulose. Which finding should the nurse expect after the administration of this medication?
- A. An increase in body temperature
- B. Neurological changes, such as confusion
- C. A change in urine specific gravity
- D. A decrease in oral fluid intake
Correct Answer: B
Rationale: A. The client’s temperature will not be affected. B. Elevated serum ammonia levels may cause neurological changes, such as confusion. C. The client’s urine specific gravity will not be affected. D. Oral fluid intake should be encouraged if tolerated by the client.
The nurse is teaching the client diagnosed with diverticulosis. Which instruction should the nurse include in the teaching session?
- A. Discuss the importance of drinking 1,000 mL of water daily.
- B. Instruct the client to exercise at least three (3) times a week.
- C. Teach the client about eating a low-residue diet.
- D. Explain the need to have daily bowel movements.
Correct Answer: B
Rationale: Regular exercise promotes bowel motility, reducing the risk of diverticulitis in diverticulosis. A high-fiber diet (not low-residue) is recommended, 1,000 mL of water is insufficient, and daily bowel movements are not mandatory.
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.
The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse?
- A. The bulb is round and has 40 mL of fluid.
- B. The drainage tube is taped to the dressing.
- C. The JP insertion site is pink and has no drainage.
- D. The JP bulb has suction and is sunken in.
Correct Answer: A
Rationale: A round JP bulb with 40 mL of fluid indicates loss of suction, risking fluid accumulation and infection, requiring immediate intervention. Taping, pink site, and suction are normal.
The nurse at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement?
- A. Stabilize the knife.
- B. Remove the knife gently.
- C. Turn the client on the side.
- D. Apply pressure to the insertion site.
Correct Answer: A
Rationale: Stabilizing the knife prevents further internal damage until surgical intervention. Removing it, turning the client, or applying pressure risks worsening bleeding.