Nokea
The client is one (1) day postoperative major abdominal surgery. Which client problem is priority?
- A. Impaired skin integrity.
- B. Fluid and electrolyte imbalance.
- C. Altered bowel elimination.
- D. Altered body image.
Correct Answer: B
Rationale: Fluid and electrolyte imbalance is the priority due to risks of dehydration or imbalances from surgery, impacting hemodynamic stability. Skin integrity, bowel elimination, and body image are secondary in the immediate postoperative period.
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The nurse is caring for the client with diverticulitis. The nurse should plan to instruct the client to avoid which food during an episode of diverticulitis?
- A. White bread
- B. Ripe banana
- C. Cooked oatmeal
- D. Iceberg lettuce
Correct Answer: C
Rationale: A. White bread is a recommended food for fiber-restricted diets. It contains less than 1 g fiber per ounce. B. Ripe bananas, canned soft fruits, and most well-cooked vegetables without seeds or skins are recommended for fiber-restricted diets. C. Cooked oatmeal contains 4 g of fiber per serving. Foods high in fiber should be avoided during an episode of diverticulitis, and foods should be restricted to low fiber or clear liquids. Once diverticulitis is resolved, the client should return to a high-fiber diet. D. Iceberg lettuce contains less than 1 g of fiber.
The 40-year-old client is recovering from an exacerbation of chronic pancreatitis. As the client prepares for discharge, the client makes several statements to the nurse. Which statement should be concerning because it could inhibit the client’s ability to accomplish the developmental tasks of middle adulthood?
- A. “I’m planning on continuing to be active in the local town service club.”
- B. “I enjoy my job; I should be able to return to work in about 3 to 4 weeks.”
- C. “I’ve missed friends and look forward to having a glass of wine with them.”
- D. “My spouse has been very supportive during my lengthy hospitalization.”
Correct Answer: C
Rationale: A. Volunteer activities meet the developmental task of middle adulthood of generativity. B. Planning to return to work meets the developmental task of middle adulthood of generativity. C. Consuming alcohol will cause continued progression of the pancreatic disease and could eventually result in the inability to work or to participate in community service. This statement should be concerning to the nurse. D. This statement indicates that the client has the support of another.
Which expected outcome should the nurse include for a client diagnosed with peptic ulcer disease?
- A. The client's pain is controlled with the use of NSAIDs.
- B. The client maintains lifestyle modifications.
- C. The client has no signs and symptoms of hemoptysis.
- D. The client takes antacids with each meal.
Correct Answer: B
Rationale: Lifestyle modifications (e.g., avoiding NSAIDs, alcohol, and trigger foods) are critical for managing peptic ulcer disease and preventing recurrence. NSAIDs worsen ulcers, hemoptysis is unrelated, and antacids are not typically taken with meals.
The nurse is caring for the client scheduled for an abdominal perineal resection for Stage IV colon cancer. Which client problem should the nurse include in the intraoperative care plan?
- A. Fluid volume deficit.
- B. Impaired tissue perfusion.
- C. Infection of surgical site.
- D. Risk for immunosuppression.
Correct Answer: A
Rationale: Fluid volume deficit is a key intraoperative concern due to blood loss and fluid shifts during abdominal perineal resection. Perfusion, infection, and immunosuppression are postoperative risks.
The client is diagnosed with esophageal diverticula. Which lifestyle modification should be taught by the nurse?
- A. Raise the foot of the bed to 45 degrees to increase peristalsis.
- B. Eat the evening meal at least two (2) hours prior to bed.
- C. Eat a low-fat, low-cholesterol, high-fiber diet.
- D. Wear an abdominal binder to strengthen the abdominal muscles.
Correct Answer: B
Rationale: Eating at least two hours before bed prevents food pooling in the diverticula, reducing regurgitation risk. Raising the bed foot, specific diets, and binders are not standard.