Nokea
The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this?
- A. Laxatives will decrease the spread of infection.
- B. Laxatives are not given prior to any type of surgery.
- C. The client does not have true constipation. She only has pressure.
- D. Laxatives could cause a rupture of the appendix.
Correct Answer: D
Rationale: Laxatives increase peristalsis, which could rupture an inflamed appendix, leading to peritonitis.
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The day after surgery in which a colostomy was performed, the client says, 'I know the doctor did not really do a colostomy.' The nurse understands that the client is in an early stage of adjustment to the diagnosis and surgery. What nursing action is indicated at this time?
- A. Agree with the client until the client is ready to accept the colostomy
- B. Say, 'It must be difficult to have this kind of surgery.'
- C. Force the client to look at his colostomy
- D. Ask the surgeon to explain the surgery to the client
Correct Answer: B
Rationale: Acknowledging the difficulty of the surgery supports the client emotionally during the denial stage without forcing confrontation.
The client is diagnosed with end-stage liver failure. The client asks the nurse, 'Why is my doctor decreasing the doses of my medications?' Which statement is the nurse's best response?
- A. You are worried because your doctor has decreased the dosage.
- B. You really should ask your doctor. I am sure there is a good reason.
- C. You may have an overdose of the medications because your liver is damaged.
- D. The half-life of the medications is altered because the liver is damaged.
Correct Answer: D
Rationale: End-stage liver failure impairs drug metabolism, prolonging medication half-life, so doses are reduced to prevent toxicity. Overdose is a consequence, not the rationale, and other responses are less informative.
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.
The nurse working in a skilled nursing facility is collaborating with the dietitian concerning the meals of an immobile client. Which foods are most appropriate for this client?
- A. Oatmeal and wheat toast.
- B. Cream of wheat and biscuits.
- C. Cottage cheese and canned peaches.
- D. Tuna on a croissant and applesauce.
Correct Answer: C
Rationale: Cottage cheese and canned peaches are soft, low-fiber, and easy to digest, suitable for an immobile client at risk for constipation. High-fiber options (oatmeal, wheat) may be harder to tolerate.
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.