Nokea
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
- A. The client verbalizes the understanding that his physical activity must be curtailed.
- B. The client states that he will place an aspirin in the drainage pouch to help control odor.
- C. The client demonstrates how to catheterize the stoma.
- D. The client states that he will empty the drainage pouch frequently throughout the day.
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.
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A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation?
- A. The client has not been including enough fiber in his diet.
- B. The client needs to increase his daily exercise.
- C. The client is experiencing an adverse effect of the aluminum hydroxide.
- D. The client has developed a gastrointestinal obstruction.
Correct Answer: C
Rationale: Aluminum hydroxide is known to cause constipation as a common adverse effect, especially with frequent dosing. The other options are less likely given the direct association with the medication.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
- A. Call the Post Anesthesia Care Unit (PACU).
- B. Call the primary care physician.
- C. Call the respiratory therapist.
- D. Call the Rapid Response Team.
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.
The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
- A. Ignore the urge to void.
- B. Force fluids.
- C. Ask for the bedpan.
- D. Ring for assistance to the bathroom.
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included?
- A. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.
- B. Lie flat on the back, splint the thorax, take two deep breaths, and cough.
- C. Take several rapid, shallow breaths and then cough forcefully.
- D. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.
Correct Answer: A
Rationale: Effective coughing in COPD involves a deep abdominal breath, bending forward, and coughing 3–4 times on exhalation to clear secretions. Other methods are less effective or impractical.