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The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
- A. Absence of bowel sounds.
- B. Temperature of 99.8°F (37.7°C).
- C. Pain at the incision site.
- D. Urine output of 30 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
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The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client
A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to
- A. discontinue the infusion.
- B. turn client to the left side.
- C. change the fluids to LR.
- D. increase the IV flow rate.
Correct Answer: A
Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration
The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following instructions should the nurse include?
- A. Take the medication with a high-protein meal
- B. Report any uncontrolled movements
- C. Stop the medication if symptoms improve
- D. Avoid regular neurological exams
Correct Answer: B
Rationale: Uncontrolled movements, such as dyskinesias, are a side effect of levodopa-carbidopa, requiring dose adjustment. Options A, C, and D are incorrect: high-protein meals reduce absorption, stopping the medication risks symptom return, and exams are essential.