Nokea
The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:
- A. Stop the administration of the enema.
- B. Lower the height of the enema container.
- C. Clamp the enema tubing and withdraw it slowly.
- D. Advance the tubing 1-2 inches.
Correct Answer: B
Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.
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The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
- A. Auscultate breath sounds to assess for crackles
- B. Monitor for >50 mL/hr urine output
- C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
- D. Press over the tibia to assess for pitting edema
Correct Answer: D
Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.
What should the nurse do when ambulating a client who has a portable wound drainage system?
- A. Remove the drainage catheter during ambulation
- B. Fasten the collection device below the wound
- C. Completely empty the collection device before ambulating
- D. Disconnect the suction apparatus from the client before ambulating
Correct Answer: B
Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
A client is admitted with pernicious anemia. The client reports all of the following. Which is most likely related to the admitting diagnosis?
- A. I often have diarrhea.'
- B. My tongue is more red and thick than usual.'
- C. I have little bruise-like spots on my arms and legs.'
- D. I have been running a fever for the last two days.'
Correct Answer: B
Rationale: Pernicious anemia, due to vitamin B12 deficiency, often causes a sore, red, beefy tongue. Diarrhea, bruising, or fever are less specific.
The nurse is caring for a client with irritable bowel syndrome. Which of the following menu selections would be appropriate to offer the client?
- A. Beans, yogurt, and a mixed fruit cup
- B. Eggs, bagel, and a cup of black coffee
- C. Baked chicken, brown rice, and strawberries
- D. Roasted beef, broccoli, and a glass of iced tea
Correct Answer: C
Rationale: Baked chicken, brown rice, and strawberries are low-FODMAP, suitable for IBS. Beans, yogurt, coffee, and broccoli are high-FODMAP, likely to trigger symptoms.