Nokea
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings should the nurse report immediately?
- A. Absence of bowel sounds.
- B. Mild abdominal distension.
- C. Pain at the incision site.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on day 2 suggests ileus or obstruction, requiring immediate reporting. Options B, C, and D are expected or normal.
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A client has a total laryngectomy with a permanent tracheostomy.
Which of the following would be necessary for the nurse to consider regarding the client's nutrition?
- A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
- C. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration.
- D. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although the client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
- A. the time and circumstances under which the rash was noted.
- B. the explanation given to the client and family of the reason for the rash.
- C. notation on an allergy list and notification of the doctor.
- D. the need for application of corticosteroid cream to decrease inflammation.
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
The nurse is caring for a client with a history of asthma who is experiencing an acute exacerbation. Which of the following medications should the nurse administer FIRST?
- A. Albuterol nebulizer.
- B. Prednisone PO.
- C. Montelukast PO.
- D. Ipratropium inhaler.
Correct Answer: A
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm and improve airflow. Options B, C, and D are secondary: prednisone reduces inflammation, montelukast prevents attacks, and ipratropium is an adjunct.