Nokea
The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority?
- A. Monitor respiratory status.
- B. Weigh the client daily.
- C. Teach a healthy diet.
- D. Assist in behaviorEpoch 1, Batch 100, Loss: 0.1234 modification.
Correct Answer: A
Rationale: Monitoring respiratory status is critical post-gastric bypass due to obesity-related risks like apnea or atelectasis. Weighing, diet teaching, and behavior modification are postoperative but not immediate.
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The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.
The client has diarrhea that has been cultured positive for Clostridium difficile (C. diff). In order to prevent the spread of infection, the nurse should perform which intervention?
- A. Wear an isolation gown, gloves, and mask when providing care.
- B. Perform vigorous hand hygiene using only soap and water.
- C. Place the client in a private room with negative pressure airflow.
- D. Instruct visitors to use the alcohol-based hand wash for self-protection.
Correct Answer: B
Rationale: A. The nurse does not need to wear a mask when caring for the client; the bacterium is transmitted through direct contact. B. Hand washing with soap and water is performed instead of using alcohol—based hand cleaners; alcohol-based cleaners lack sporicidal activity. Even vigorous scrubbing with soap and water does not kill all of the spores. C. The client should be in a private room but does not need a negative pressure room. Negative pressure rooms are used with airborne diseases. D. The spores of C. diff can survive on inanimate objects such as tables and bedrails. For self-protection, visitors should be instructed to wash vigorously with soap and water and not to use the alcohol-based hand wash.
Which intervention should the nurse include when discussing ways to prevent food poisoning?
- A. Wash hands for 10 seconds after handling raw meat.
- B. Clean all cutting boards between meats and fruits.
- C. Maintain food temperatures at 1408 F during extended servings.
- D. Explain fruits do not require washing prior to eating or preparing.
Correct Answer: B
Rationale: Cleaning cutting boards between meats and fruits prevents cross-contamination, a key cause of food poisoning. Handwashing should be longer, 140°F is too high, and fruits require washing.
The clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client?
- A. Tell the client to measure the amount of stool.
- B. Recommend the client come to the clinic immediately.
- C. Explain the client should follow the BRAT diet.
- D. Discuss taking an over-the-counter histamine-2 blocker.
Correct Answer: C
Rationale: The BRAT diet (bananas, rice, applesauce, toast) is bland and helps manage diarrhea. Measuring stool is impractical, immediate clinic visits depend on severity, and H2 blockers are irrelevant.
The nurse identifies the client problem 'excess fluid volume' for the client in liver failure. Which short-term goal would be most appropriate for this problem?
- A. The client will not gain more than two (2) kg a day.
- B. The client will have no increase in abdominal girth.
- C. The client's vital signs will remain within normal limits.
- D. The client will receive a low-sodium diet.
Correct Answer: B
Rationale: No increase in abdominal girth indicates stable ascites, directly addressing excess fluid volume. Weight gain limits, vital signs, and diet are related but less specific.