Nokea
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
- A. Reassure the client that the nasoenteric tube is functioning.
- B. Assess the client for a rigid abdomen.
- C. Administer an opioid as ordered.
- D. Reposition the client on the left side.
Correct Answer: B
Rationale: Persistent acute pain despite a patent nasoenteric tube suggests a complication like peritonitis, indicated by a rigid abdomen, which requires immediate assessment. Reassurance, opioids, or repositioning may delay addressing a serious issue. CN: Physiological adaptation; CL: Synthesize
You may also like to solve these questions
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?
- A. valacyclovir
- B. zidovudine
- C. amphotericin b
- D. metronidazole
Correct Answer: B
Rationale: Zidovudine (AZT) is used during labor in HIV-positive clients to reduce the risk of perinatal transmission of HIV. Choice A (valacyclovir) is for herpes, Choice C (amphotericin B) is for fungal infections, and Choice D (metronidazole) is for bacterial/parasitic infections.
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply.
- A. I will need to dispose of my old clothing when I return home.
- B. I should always cover my mouth and nose when sneezing.
- C. I'll be important that I isolate myself from family when possible.
- D. I should use paper tissues to cough in and dispose of them promptly.
- E. I can use regular plates and utensils whenever I eat.
Correct Answer: B,D,E
Rationale: Covering the mouth when sneezing (B), using tissues for coughing and disposing of them (D), and using regular utensils (E) prevent tuberculosis spread. Disposing of clothing is unnecessary. Isolation is only needed until the client is non-infectious (after 2–3 weeks of treatment).
A client who has had an above-the-knee amputation is to have a dressing change 45 minutes after arriving in the postanesthesia recovery unit. The nurse should:
- A. Elevate the stump.
- B. Reinforce the dressing.
- C. Call the surgeon.
- D. Draw a mark around the site.
Correct Answer: C
Rationale: Excessive bleeding requires the surgeon's evaluation to prevent complications.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.