Nokea
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.
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An upper GI series is ordered for a client. Which action is essential for the nurse before the test?
- A. Check to see if the client has an allergy to shellfish.
- B. Instruct the client to have nothing to eat after midnight the night before the test.
- C. Encourage the client to drink plenty of liquids before the test.
- D. Be sure the client does not eat fat-containing foods for 18 hours before the test.
Correct Answer: B
Rationale: Preparation for an upper GI series requires NPO for eight hours to ensure a clear view of the GI tract. Shellfish allergies are irrelevant as iodine dye is not used, and fat restriction applies to gallbladder tests.
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.
The nurse is preparing a client with Crohn's disease for discharge. Which of the following statements indicates that he needs further teaching?
- A. Stress can make it worse.'
- B. Since I have Crohn's disease, I don't have to worry about colon cancer.'
- C. I realize I shall always have to monitor my diet.'
- D. I understand there is a high incidence of familial occurrence with this disease.'
Correct Answer: B
Rationale: Crohn’s disease increases the risk of colon cancer, so the statement indicates a need for further teaching. The other statements are correct.
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
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.