Nokea
The client is diagnosed with gastroenteritis. Which laboratory data warrant immediate intervention by the nurse?
- A. A serum sodium level of 137 mEq/L.
- B. Arterial blood gases of pH 7.37, PaO2 95, PaCO2 43, HCO3 24.
- C. A serum potassium level of 3.3 mEq/L.
- D. A stool sample positive for fecal leukocytes.
Correct Answer: C
Rationale: A potassium level of 3.3 mEq/L indicates hypokalemia, risking arrhythmias, especially with diarrhea-related losses, requiring immediate intervention. Normal sodium, ABGs, and fecal leukocytes are less urgent.
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The client diagnosed with Crohn's disease is crying and tells the nurse, 'I can't take it anymore. I never know when I will get sick and end up here in the hospital.' Which statement is the nurse's best response?
- A. I understand how frustrating this must be for you.
- B. You must keep thinking about the good things in your life.
- C. I can see you are very upset. I'll sit down and we can talk.
- D. Are you thinking about doing anything like committing suicide?
Correct Answer: C
Rationale: Acknowledging the client's distress and offering to talk provides emotional support and opens communication to address concerns. The other responses are less therapeutic, either minimizing the issue or jumping to assumptions about suicide risk.
A client has had a liver biopsy. After the procedure, the nurse should position him on his right side with a pillow under his rib cage. What is the primary reason for this position?
- A. To immobilize the diaphragm
- B. To facilitate full chest expansion
- C. To minimize the danger of aspiration
- D. To reduce the likelihood of bleeding
Correct Answer: D
Rationale: Right-side positioning with a pillow applies pressure to the biopsy site, reducing the risk of bleeding.
A client is to have a sigmoidoscopy in the morning. Which activity will be included in the care of this client?
- A. Give him an enema one hour before the examination.
- B. Keep him NPO for eight hours before the examination.
- C. Order a low-fat, low-residue diet for breakfast.
- D. Administer enemas until the returns are clear this evening.
Correct Answer: A
Rationale: An enema one hour before sigmoidoscopy clears the sigmoid colon for better visualization.
The client diagnosed with a hiatal hernia is scheduled for a laparoscopic Nissen fundoplication. Which statement indicates the nurse's teaching is effective?
- A. I will have four (4) to five (5) small incisions.
- B. I will be in the hospital for at least one (1) week.
- C. I will not have any pain because this is laparoscopic surgery.
- D. I will be returning to work the day after my surgery.
Correct Answer: A
Rationale: Laparoscopic Nissen fundoplication involves 4–5 small incisions, indicating effective teaching. Hospital stays are shorter, pain is expected, and return to work takes longer.
The public health nurse is discussing hepatitis B with a group in the community. Which health promotion activities should the nurse discuss with the group?
- A. Do not share needles or equipment.
- B. Use barrier protection during sex.
- C. Get the hepatitis B vaccine.
- D. Obtain immune globulin injections.
- E. Avoid any type of hepatotoxic medications.
Correct Answer: A,B,C
Rationale: Preventing hepatitis B involves avoiding needle sharing, using condoms, and getting vaccinated, as it is bloodborne and sexually transmitted. Immune globulin is post-exposure, and hepatotoxic drugs are less relevant.