Nokea
The HCP writes the following admission orders for the client with possible appendicitis. Which order should the nurse question?
- A. Place on NPO (nothing per mouth) status.
- B. No analgesics until diagnosis is confirmed.
- C. Apply heat to abdomen to decrease pain.
- D. Start IV lactated Ringer’s at 125 mL/hr.
Correct Answer: C
Rationale: A. Clients are kept NPO in case surgery is needed. B. Analgesic medications are usually withheld until a definitive diagnosis is established to avoid masking critical symptom changes. C. The nurse should question applying heat to the abdomen when appendicitis is suspected. Heat is contraindicated because it increases circulation, which, in turn, could cause the appendix to rupture. D. Isotonic IV fluids are initiated to replace lost body fluid and prevent dehydration.
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The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication?
- A. It is administered rectally to help decrease colon inflammation.
- B. This medication slows gastrointestinal (GI) motility and reduces diarrhea.
- C. This medication kills the bacteria causing the exacerbation.
- D. It acts topically on the colon mucosa to decrease inflammation.
Correct Answer: D
Rationale: Sulfasalazine reduces inflammation in IBD by acting topically on the colon mucosa, delivering its active component (mesalamine) to the inflamed areas. It is not primarily an antibiotic, does not slow motility, and is taken orally, not rectally.
The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.
The client who has had a hemorrhoidectomy wants to know why she cannot take a sitz bath immediately upon return from the operating room. The nurse's response is based on which of the following concepts?
- A. Heat can stimulate bowel movement too quickly after surgery.
- B. Clients are generally not awake enough for several hours to safely take sitz baths.
- C. Heat applied immediately postoperatively increases the possibility of hemorrhage.
- D. Sitting in water before the sutures are removed may cause infection.
Correct Answer: C
Rationale: Heat increases blood flow, raising the risk of hemorrhage immediately post-hemorrhoidectomy.
The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first?
- A. Ask the client why she is eating too much.
- B. Refer the client to a gymnasium for exercise.
- C. Have the client set a realistic weight loss goal.
- D. Determine the client's eating patterns.
Correct Answer: D
Rationale: Determining eating patterns identifies triggers and habits, guiding weight loss interventions. Asking why is confrontational, gym referral is premature, and goal-setting follows assessment.
The nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data require further intervention?
- A. Bowel sounds auscultated 15 times in one (1) minute.
- B. Belching after eating a heavy and fatty meal late at night.
- C. A decrease in systolic blood pressure (BP) of 20 mm Hg from lying to sitting.
- D. A decreased frequency of distress located in the epigastric region.
Correct Answer: C
Rationale: A 20 mm Hg drop in systolic BP on positional change suggests orthostatic hypotension, possibly from bleeding, requiring immediate intervention. Normal bowel sounds, belching, and reduced pain are less concerning.