Nokea
The nurse is admitting a client with the diagnosis of appendicitis to the surgical unit. Which question is it essential to ask?
- A. When did you last eat?'
- B. Have you had surgery before?'
- C. Have you ever had this type of pain before?'
- D. What do you usually take to relieve your pain?'
Correct Answer: A
Rationale: Knowing when the client last ate is essential to minimize aspiration risk during anesthesia for anticipated appendicitis surgery.
You may also like to solve these questions
The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching is effective?
- A. I will brush my teeth with a soft-bristle toothbrush.
- B. I will rinse my mouth with Listerine mouthwash.
- C. I will swish with antifungal solution and then swallow.
- D. I will avoid spicy foods, tobacco, and alcohol.
Correct Answer: D
Rationale: Avoiding spicy foods, tobacco, and alcohol reduces irritation of mouth ulcers, indicating effective teaching. Soft brushes help, Listerine may irritate, and antifungal solutions are for candidiasis.
The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.
The client at the eating disorder clinic weighs 35 kg and is 5 ft 7 inches tall. Which would the nurse document as the Body Mass Index (BMI)?
Correct Answer: 11.5
Rationale: BMI = weight (kg) / height (m)^2. Height = 5'7 = 1.73 m. BMI = 35 / (1.73)^2 = 35 / 2.9929 ≈ 11.5.
The client has severe liver disease. Which of the following observations is most indicative of serious problems?
- A. The client has generalized urticaria.
- B. The client is 'confused' and can no longer write his name legibly.
- C. The client is jaundiced.
- D. The client has ecchymotic areas on his arms.
Correct Answer: B
Rationale: Confusion and impaired handwriting suggest hepatic encephalopathy, a serious complication of liver disease due to ammonia buildup.
The client with Crohn’s disease has undergone a barium enema that showed strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of which complication?
- A. Peritonitis
- B. Obstruction
- C. Malabsorption
- D. Fluid imbalance
Correct Answer: B
Rationale: A. Peritonitis would not be an expected consequence of a bowel stricture. B. The nurse should monitor for signs of a bowel obstruction. Bowel strictures are a common complication of Crohn’s disease and can result in an acute bowel obstruction. C. Malabsorption would not be an expected consequence of a bowel stricture. D. Fluid balance would be affected once total obstruction develops.