Nokea
The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?
- A. Urine specific gravity value of 1.020
- B. High-pitched and tinkling bowel sounds
- C. Decreased lung sounds in both lung bases
- D. Client describes abdominal pain as colicky
Correct Answer: C
Rationale: Decreased lung sounds are the most concerning finding because it can be life-threatening. Massive distention can impair function of the diaphragm, which in turn leads to atelectasis and compromised respiratory function.
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The client is scheduled for an abdominal-perineal resection for cancer of the rectum. Which components should the nurse include in the client’s preoperative education? Select all that apply.
- A. The enterostomal nurse will be visiting the client prior to surgery.
- B. After surgery rectal suppositories will be given to prevent straining and stress.
- C. The bowel will be cleansed before surgery with a laxative, enema, or whole-gut lavage.
- D. Oral or intravenous (IV) antibiotics will be prescribed to be given preoperatively.
- E. A member of the surgical team will discuss the risk of postoperative sexual dysfunction.
Correct Answer: A,C,D,E
Rationale: An abdominal-perineal resection removes the sigmoid colon, rectum, and anus. As a result the client will have a permanent colostomy. The enterostomal nurse will identify and mark an appropriate stoma location after considering the client’s skinfolds, clothing preferences, and the level of the colostomy. The bowel is cleansed preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Antibiotics are prescribed to be given preoperatively to reduce the risk of peritoneal contamination by bowel contents during surgery. Postoperatively the client with an abdominal-perineal resection is at risk for sexual dysfunction and urinary incontinence as a result of nerve damage. This needs to be discussed with the client prior to surgery by the surgeon or a member of the surgical team.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.
The client who has had an appendectomy and has a Penrose drain in place has recovered from anesthesia. The nurse places her in a semi-sitting position. What is the primary reason for selecting this position?
- A. To promote optimal ventilation
- B. To promote drainage from the abdominal cavity
- C. To prevent pressure sores from developing
- D. To reduce tension on the suture line
Correct Answer: B
Rationale: The semi-sitting position promotes gravity-dependent drainage through the Penrose drain from the abdominal cavity.
Warm oatmeal (Aveeno) baths are ordered for a client with cancer of the pancreas. What is the chief purpose of this procedure for this client?
- A. Relief of paralytic ileus
- B. Alleviation of pruritus associated with jaundice
- C. Relief of bloating and fullness after eating
- D. Reducing the fever associated with the disease
Correct Answer: B
Rationale: Oatmeal baths alleviate pruritus caused by jaundice, a common symptom in pancreatic cancer due to bile salt accumulation.
A client with cirrhosis is about to have a paracentesis for relief of ascites. Which activity is essential prior to the procedure?
- A. Administer thorough mouth care.
- B. Ask the client to empty his bladder.
- C. Be sure his bowels have moved recently.
- D. Have the client bathe with betadine.
Correct Answer: B
Rationale: Emptying the bladder prevents accidental puncture during paracentesis, which involves inserting a needle into the abdominal cavity.