Nokea
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
- A. Take a laxative.
- B. Follow a clear liquid diet.
- C. Administer an enema.
- D. Take an antiemetic.
Correct Answer: A
Rationale: A laxative is typically recommended after an upper GI series to help eliminate the barium used in the procedure and prevent constipation.
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A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
- A. The client complains of a sore throat.
- B. The client displays signs of sedation.
- C. The client experiences a sudden increase in temperature.
- D. The client demonstrates a lack of appetite.
Correct Answer: C
Rationale: A sudden increase in temperature post-endoscopy may indicate a complication such as perforation or infection, requiring immediate assessment. Sore throat, sedation, and lack of appetite are expected or unrelated findings.
When planning to move a person with a possible spinal cord injury, the nurse should direct the team to:
- A. Limit movement of the arms by wrapping them next to the body.
- B. Move the person gently to help reduce pain.
- C. Immobilize the head and neck to prevent further injury.
- D. Cushion the back with pillows to ensure comfort.
Correct Answer: C
Rationale: Immobilizing the head and neck prevents exacerbation of a spinal cord injury during movement.
The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply.
- A. Rapid pulse.
- B. Decreased energy and fatigue.
- C. Weight gain of 10 lb.
- D. Fine, thin hair with hair loss.
- E. Constipation.
- F. Monorrhagia.
Correct Answer: B,C,D,E,F
Rationale: Hypothyroidism slows metabolism, leading to decreased energy, fatigue, weight gain, hair loss, constipation, and heavy menstrual periods (menorrhagia). Rapid pulse is associated with hyperthyroidism, not hypothyroidism.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.