Nokea
The experienced nurse is teaching the new nurse about surgery to repair a hiatal hernia. The experienced nurse is most likely to state that the surgery is becoming more common to prevent which emergency complication?
- A. Severe dysphagia
- B. Esophageal edema
- C. Hernia strangulation
- D. Aspiration
Correct Answer: C
Rationale: A. Although dysphagia is a complication of hiatal hernia, it is not an emergency condition. B. Esophageal edema is not a complication of hiatal hernia. C. A hiatal hernia can become strangulated (Circulation of blood to the hernia is cut off by constriction). Strangulation can occur with any type of hernia. D. Although aspiration is a complication of hiatal hernia, it is not an emergency condition.
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The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.
The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse?
- A. The bulb is round and has 40 mL of fluid.
- B. The drainage tube is taped to the dressing.
- C. The JP insertion site is pink and has no drainage.
- D. The JP bulb has suction and is sunken in.
Correct Answer: A
Rationale: A round JP bulb with 40 mL of fluid indicates loss of suction, risking fluid accumulation and infection, requiring immediate intervention. Taping, pink site, and suction are normal.
The client is admitted with upper right-side abdominal pain. The nurse is concerned that the client may have liver cancer when which serum laboratory test results are elevated?
- A. Creatinine and BUN
- B. α-fetoprotein (AFP)
- C. Phosphorus levels
- D. CA-125 levels
Correct Answer: B
Rationale: A. Elevated serum creatinine and BUN are associated with renal problems. B. Serum α-fetoprotein is a major serum protein synthesized by fetal liver cells, by yolk sac cells, and in small amounts by the fetal GI system. Reappearance of AFP in adults signals pathological problems. In 50% to 75% of clients with liver cancer, serum AFP levels are elevated. C. Elevated serum phosphorus is associated with renal and many other diseases and is not specific to liver cancer. D. CA-125 is a tumor marker for ovarian cancer.
A client with pancreatitis tells the nurse that he fears nighttime. Which of the following statements most likely relates to the client's concerns?
- A. The pain is aggravated in the recumbent position.
- B. The client has fewer distractions at night.
- C. The mattress is uncomfortable.
- D. The pain increases after a day of activity.
Correct Answer: A
Rationale: Pancreatitis pain is often worsened in the recumbent position, contributing to the client’s fear of nighttime.
The client diagnosed with end-stage liver failure is admitted with hepatic encephalopathy. Which dietary restriction should be implemented by the nurse to address this complication?
- A. Restrict sodium intake to 2 g/day.
- B. Limit oral fluids to 1,500 mL/day.
- C. Decrease the daily fat intake.
- D. Reduce protein intake to 60 to 80 g/day.
Correct Answer: D
Rationale: Reducing protein intake limits ammonia production, which exacerbates hepatic encephalopathy. Sodium, fluid, and fat restrictions are less directly related to this complication.