Nokea
The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:
- A. Document the finding and continue to monitor the client
- B. Irrigate the drainage tube with 10 mL of normal saline
- C. Decrease the amount of intermittent suction
- D. Notify the physician of the findings
Correct Answer: D
Rationale: Increased bile-tinged drainage may indicate a complication, such as a leak, requiring physician notification.
You may also like to solve these questions
Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. A granola bar
- B. A bran muffin
- C. Yogurt
- D. Raisins
Correct Answer: C
Rationale: Yogurt is rich in calcium, which is essential for bone health in osteoporosis management.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
The nurse is admitting a client directly from a health provider's office. The client has a rash and has been diagnosed with measles. Which room assignment by the nurse indicates an understanding of the disease process of measles?
- A. a private negative-pressure room
- B. a semiprivate room with a client who has a broken femur
- C. a semiprivate room with a client diagnosed with type 1 diabetes
- D. a private room at the end of the hall away from the nurses' station
Correct Answer: A
Rationale: Measles requires airborne precautions, necessitating a private negative-pressure room to prevent transmission.
The nurse is caring for a client scheduled for a surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
- A. Assessment of the client's level of anxiety
- B. Evaluation of the client's exercise tolerance
- C. Identification of peripheral pulses
- D. Assessment of bowel sounds and activity
Correct Answer: C
Rationale: Identifying peripheral pulses is critical to establish a baseline for vascular status, as an abdominal aortic aneurysm repair can affect blood flow to the extremities, and postoperative complications may include vascular occlusion.
A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.