Nokea
The client presents to the outpatient clinic complaining of diarrhea for two (2) days. Which laboratory data should the nurse monitor?
- A. The sodium level.
- B. The albumin level.
- C. The potassium level.
- D. The glucose level.
Correct Answer: C
Rationale: Potassium is critical to monitor in diarrhea due to risk of hypokalemia from losses, which can cause arrhythmias. Sodium is also relevant, but potassium is priority.
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The nurse is teaching a client recovering from a laparoscopic cholecystectomy. Which statement indicates the discharge teaching is effective?
- A. I will take my lipid-lowering medicine at the same time each night.
- B. I may experience some discomfort when I eat a high-fat meal.
- C. I need someone to stay with me for about a week after surgery.
- D. I should not splint my incision when I deep breathe and cough.
Correct Answer: B
Rationale: High-fat meals may cause discomfort post-cholecystectomy due to altered bile flow, indicating understanding of dietary adjustments. Lipid-lowering drugs, prolonged supervision, and avoiding splinting are incorrect.
The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
- A. White blood cells (WBCs) elevated
- B. Temperature of 101°F (38.3°C)
- C. Bowel sounds are absent
- D. Reports intense abdominal pain
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
The nurse is assessing the client in end-stage liver failure who is diagnosed with portal hypertension. Which intervention should the nurse include in the plan of care?
- A. Assess the abdomen for a tympanic wave.
- B. Monitor the client's blood pressure.
- C. Percuss the liver for size and location.
- D. Weigh the client twice each week.
Correct Answer: B
Rationale: Monitoring blood pressure detects complications of portal hypertension, like variceal bleeding. Tympanic wave is incorrect, liver percussion is less urgent, and weight checks are secondary.
The nurse is reviewing the history and physical of a teenager admitted to a hospital with a diagnosis of ulcerative colitis. Based on this diagnosis, which information should the nurse expect to see on this client’s medical record?
- A. Heartburn and regurgitation
- B. Abdominal pain and bloody diarrhea
- C. Weight gain and elevated blood glucose
- D. Abdominal distention and hypoactive bowel sounds
Correct Answer: B
Rationale: A. Heartburn and regurgitation are not symptoms of ulcerative colitis. B. The nurse should expect to read about the primary symptoms of ulcerative colitis, which are bloody diarrhea and abdominal pain. C. Weight loss, not weight gain, often occurs in severe cases of ulcerative colitis. D. Bowel sounds are often hyperactive rather than hypoactive in ulcerative colitis.
The school nurse is discussing methods to prevent an outbreak of hepatitis A with a group of high school teachers. Which action is the most important to teach the high school teachers?
- A. Do not allow students to eat or drink after each other.
- B. Drink bottled water as much as possible.
- C. Encourage protected sexual activity.
- D. Sing the happy birthday song while washing hands.
Correct Answer: D
Rationale: Handwashing (e.g., for the duration of singing 'Happy Birthday') is the most effective way to prevent fecal-oral transmission of hepatitis A in a school setting. Sharing food/drink is a risk but less critical than hygiene.