Nokea
The nurse is caring for a client post-colonoscopy. Which finding requires immediate intervention?
- A. Mild abdominal cramping
- B. Bright red blood in the stool
- C. Slight drowsiness
- D. Flatulence
Correct Answer: B
Rationale: Bright red blood in the stool suggests post-colonoscopy bleeding, possibly from perforation, requiring immediate intervention. Cramping (A), drowsiness (C), and flatulence (D) are expected.
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Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
- A. The client will settle down more quickly if he thinks the staff is medicating him
- B. The medication will sedate the client until the physician arrives
- C. Haloperidol is a minor tranquilizer and will not oversedate the client
- D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:
- A. Reinforce the dressing.
- B. Continue to monitor the dressing.
- C. Notify the physician.
- D. Note the time and amount of blood.
Correct Answer: C
Rationale: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
The nurse is teaching a client with a new colostomy about dietary management. Which food should the client avoid to reduce odor?
- A. Broccoli
- B. Rice
- C. Chicken
- D. Yogurt
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, increases colostomy odor due to sulfur compounds. Rice (B), chicken (C), and yogurt (D) are odor-neutral and appropriate.