Nokea
The client who has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor has a nasogastric tube (NGT) in place and an IV running at 150 mL/hr via an IV pump. Which data should be reported to the HCP?
- A. The pump keeps sounding an alarm indicating the high pressure has been reached.
- B. Intake is 1,800 mL, NGT output is 550 mL, and Foley output is 950 mL.
- C. On auscultation, crackles and rhonchi in all lung fields are noted.
- D. Client has negative pedal edema and an increasing level of consciousness.
Correct Answer: C
Rationale: Crackles and rhonchi suggest pulmonary edema, a critical complication possibly due to fluid overload, requiring immediate HCP notification. Pump alarms, intake/output, and edema status are less urgent unless associated with other critical findings.
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The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.
When the client complains about the bland taste of the food, the nurse appropriately recommends substituting salt with a bloodiness?
- A. Catsup
- B. Mustard
- C. Soy sauce
- D. Lemon juice
Correct Answer: D
Rationale: Lemon juice is a low-sodium flavor enhancer, suitable for a sodium-restricted diet, unlike catsup, mustard, or soy sauce.
Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective?
- A. The client prepares a scheduled voiding plan.
- B. The client verbalizes the need to increase fluid intake.
- C. The client explains how to perform pelvic floor exercises.
- D. The client attempts to retain the vaginal cone in place the entire day.
Correct Answer: C
Rationale: Pelvic floor (Kegel) exercises strengthen muscles to reduce incontinence, indicating effective teaching. Scheduled voiding is a strategy, increased fluids may worsen incontinence, and vaginal cones are not used all day.
The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client?
- A. Fluid volume loss.
- B. Knowledge deficit.
- C. Impaired urinary elimination.
- D. Alteration in comfort.
Correct Answer: D
Rationale: Severe pain (alteration in comfort) is the priority in acute ureteral calculi, as it affects the client’s immediate well-being and requires prompt management. Fluid loss, urinary elimination, and knowledge are secondary.
Which nursing intervention promotes the spontaneous passage of ureteral stones?
- A. Encouraging ambulation as tolerated
- B. Restricting fluid intake
- C. Administering diuretics
- D. Keeping the client on bed rest
Correct Answer: A
Rationale: Encouraging ambulation promotes gravity-assisted stone movement through the ureter, facilitating spontaneous passage.