Nokea
The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.
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A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
A standard walker is used when clients:
- A. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- B. have poor balance, have a broken leg, or have experienced amputation.
- C. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- D. have poor balance, have an autoimmune disease, or have weak arms.
Correct Answer: C
Rationale: A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward.
The client began wearing hearing aids 5 weeks earlier. Which statement to the nurse demonstrates that the client is successfully adapting to the hearing aids?
- A. I need to wear the hearing aids only when I go out in public.
- B. I clean my ears with a cotton-tipped swab before I insert them.
- C. I place the hearing aids in the protective box to store them at night.
- D. I soak the plastic parts of the hearing aids in mild soap and water weekly.
Correct Answer: C
Rationale: C: Hearing aids are expensive and delicate, and they should be stored in a protective container in a dry, safe place. A: Hearing aids should be worn daily to adjust to their use. B: Cotton-tipped swabs should not be inserted into the ear canal due to possible injury and infection. D: Hearing aids should be kept dry except when cleaning the ear mold with mild soap and water.
Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to examine and question the bill
- B. the right to reasonable response to requests
- C. the right to refuse treatment
- D. the right to confidentiality
Correct Answer: D
Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.
Accurate documentation of assessment findings regarding pressure ulcers is very important because:
- A. The law requires the nurse to document lesions
- B. The hospital requires the nurse to document lesions
- C. The physician requires the nurse to document lesions
- D. The nursing assessment of ulcers is a standard of nursing practice
Correct Answer: D
Rationale: Documenting pressure ulcers is a nursing standard to promote continuity of care and prevent progression, not merely a legal or institutional requirement.