Nokea
The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse?
- A. Absent bowel sounds in all four (4) quadrants.
- B. The T-tube has 60 mL of green drainage.
- C. Urine output of 100 mL in the past three (3) hours.
- D. Refusal to turn, deep breathe, and cough.
Correct Answer: D
Rationale: Refusal to turn, deep breathe, and cough increases the risk of atelectasis and pneumonia post-surgery, requiring immediate intervention. Absent bowel sounds, T-tube drainage, and urine output are expected at this stage.
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Which diagnostic test should the nurse monitor for the client diagnosed with severe anorexia nervosa?
- A. Liver function tests.
- B. Kidney function tests.
- C. Cardiac function tests.
- D. Bone density scan.
Correct Answer: C
Rationale: Cardiac function tests (e.g., ECG) monitor for arrhythmias or heart failure, common in severe anorexia due to electrolyte imbalances and starvation. Liver, kidney, and bone tests are less urgent.
The nurse is admitting a client diagnosed with protein calorie malnutrition. Which interventions should the nurse implement? Select all that apply.
- A. Place the client on a 72-hour calorie count.
- B. Ask the client to describe the stools.
- C. Have the UAP weigh the client.
- D. Obtain a list of current medications.
- E. Make a referral to the dietitian.
Correct Answer: A,C,D,E
Rationale: Calorie count, weight, medication list, and dietitian referral assess and manage malnutrition. Stool description is less relevant unless GI issues are present.
The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client’s anxiety?
- A. “This surgery will prevent you from developing colon cancer.”
- B. “After this surgery you will no longer have ulcerative colitis.”
- C. “After surgery you may not have solid food for several days.”
- D. “You’ll have a permanent ileostomy after having this surgery.”
Correct Answer: D
Rationale: A. The client will not be at risk for colon cancer because with a total colectomy the entire colon is removed. B. Since this surgery removes the total colon, the ulcerative colitis will be cured. C. The client will be unable to eat until peristalsis returns, and then it may take several days before solid foods are tolerated. D. The client will initially have an ileostomy; after the reservoir has healed, the ileostomy will be closed. Knowing that the ileostomy will be temporary is important information for the client to decrease anxiety.
The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
- A. No bowel movement.
- B. Oxygen saturation 96%.
- C. Vital signs within normal baseline.
- D. Intact gag reflex.
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy?
- A. My stoma should be pink and moist.
- B. I will irrigate my ileostomy every morning.
- C. If I get a red, bumpy, itchy rash I will call my HCP.
- D. I will change my pouch if it starts leaking.
Correct Answer: B
Rationale: Ileostomies typically do not require routine irrigation, as the output is liquid and continuous, unlike colostomies. The other statements reflect correct understanding of stoma care and management.