Nokea
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.
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The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
The female nurse sticks herself with a contaminated needle. Which action should the nurse implement first?
- A. Notify the infection control nurse.
- B. Cleanse the area with soap and water.
- C. Request postexposure prophylaxis.
- D. Check the hepatitis status of the client.
Correct Answer: B
Rationale: Cleansing the area with soap and water immediately reduces infection risk, including hepatitis. Notification, prophylaxis, and checking status follow after initial decontamination.
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 is assessing the integumentary system of the client diagnosed with anorexia nervosa. Which finding supports the diagnosis?
- A. Preoccupation with calories.
- B. Thick body hair.
- C. Sore tongue.
- D. Dry, brittle hair.
Correct Answer: D
Rationale: Dry, brittle hair is a common integumentary finding in anorexia nervosa due to malnutrition. Preoccupation is psychological, thick hair is unrelated, and sore tongue is less specific.
Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.