Nokea
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750ml of green-brown drainage. Which nursing intervention is most appropriate?
- A. Notify the physician
- B. Document the findings
- C. Irrigate the T-tube
- D. Clamp the T-tube
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments made after the procedure would indicate the development of a potential complication?
- A. The client complains of a sore throat
- B. The client displays signs of sedation
- C. The client experiences a sudden increase in temperature
- D. The client demonstrates a lack of appetite
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery for 2 hours. The client begins to complain of increases abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen distended and bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?
- A. Administer the prescribed pain medication.
- B. Notify the physician.
- C. Call and ask the operating room team to perform the surgery as soon as possible.
- D. Reposition the client and apply a heating pad on warm setting to the client's abdomen.
Correct Answer: B
Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and should notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time.
The nurse is reviewing the record of a client with Crohn's disease. Which of the following stool characteristics would the nurse expect to note documented in the client's record?
- A. Chronic constipation
- B. Diarrhea
- C. Constipation alternating with diarrhea
- D. Stool constantly oozing from the rectum
Correct Answer: B
Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Chronic constipation (Choice A), constipation alternating with diarrhea (Choice C), and stool constantly oozing from the rectum (Choice D) are not characteristics typically associated with Crohn's disease.
When counseling a client in ways to prevent cholecystitis, which of the following guidelines is most important?
- A. Eat a low-protein diet
- B. Eat a low-fat, low-cholesterol diet
- C. Limit exercise to 10 minutes/day
- D. Keep weight proportionate to height
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has best understanding of the dietary measures to follow of the client states an intention to increase intake of:
- A. Pork
- B. Milk
- C. Chicken
- D. Broccoli
Correct Answer: A
Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Broccoli contains vitamins C, E, and K and folic acid.