Nokea
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.
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Which interventions should the nurse discuss regarding prevention of an acute exacerbation of diverticulosis? Select all that apply.
- A. Eat a low-fiber diet.
- B. Drink 2,500 mL of water daily.
- C. Avoid eating foods with seeds.
- D. Walk 30 minutes a day.
- E. Take an antacid every two (2) hours.
Correct Answer: B,C,D
Rationale: High fluid intake (2,500 mL), avoiding seeds, and exercise (walking) prevent constipation and reduce diverticulitis risk. Low-fiber diets worsen diverticulosis, and antacids are irrelevant.
The client with a history of peptic ulcer disease is admitted into the intensive care department with frank gastric bleeding. Which priority intervention should the nurse implement?
- A. Maintain a strict record of intake and output.
- B. Insert a nasogastric (NG) tube and begin saline lavage.
- C. Assist the client with keeping a detailed calorie count.
- D. Provide a quiet environment to promote rest.
Correct Answer: B
Rationale: Inserting an NG tube with saline lavage helps remove blood, assess bleeding severity, and stabilize the client with frank gastric bleeding. Intake/output monitoring, calorie counts, and rest are secondary to controlling active hemorrhage.
Which statement indicates to the emergency department nurse the client diagnosed with acute gastroenteritis understands the discharge teaching?
- A. I will probably have some leg cramps while I have gastroenteritis.
- B. I should decrease my fluid intake until the diarrhea subsides.
- C. I should reintroduce solid foods very slowly back into my diet.
- D. I should only drink bottled water until the abdominal cramping stops.
Correct Answer: C
Rationale: Slowly reintroducing solid foods prevents GI irritation, indicating understanding of gastroenteritis recovery. Leg cramps are possible but not emphasized, and decreasing fluids or bottled water is incorrect.
Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
Which data should the nurse expect to assess in the client who had an upper gastrointestinal (UGI) series?
- A. Chalky white stools.
- B. Increased heart rate.
- C. A firm, hard abdomen.
- D. Hyperactive bowel sounds.
Correct Answer: A
Rationale: A UGI series uses barium, which can cause chalky white stools as it is excreted. Heart rate, abdominal firmness, and bowel sounds are not typically affected.