Nokea
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
- A. Administer an antidiarrheal as ordered.
- B. Encourage a high-fiber diet.
- C. Schedule meals earlier in the day.
- D. Provide a bedside commode.
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize
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Which of the following would be a significant intervention to help prevent lung cancer?
- A. Encourage cigarette smokers to have yearly access to drugs.
- B. Instruct people about techniques for smoking cessation.
- C. Recommend that people have their houses and apartments checked for asbestos leakage.
- D. Encourage people to install central air cleaners in their homes.
Correct Answer: B
Rationale: Smoking cessation is the most effective intervention to prevent lung cancer, as smoking is the leading cause. Screening (not 'access to drugs'), asbestos checks, and air cleaners are less impactful.
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
- A. Initiating I.V. sedation.
- B. Starting a high-protein diet.
- C. Providing pain medication.
- D. Increasing the ventilator rate.
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
The nurse is caring for a client with a hyphema. The nurse should plan to take which action?
- A. Shield the affected eye.
- B. Place the client supine.
- C. Apply a cold compress to the eye.
- D. Request a prescription for aspirin.
Correct Answer: A
Rationale: Shielding the affected eye protects it from further injury in hyphema (blood in the anterior chamber). Supine positioning may worsen bleeding, cold compresses are not standard, and aspirin increases bleeding risk.
A client is to have a Schilling test. The nurse should:
- A. Administer methylcellulose (Citrucel).
- B. Start a 24- to 48-hour urine specimen collection.
- C. Maintain nothing-by-mouth (NPO) status.
- D. Start a 72-hour stool specimen collection.
Correct Answer: B
Rationale: The Schilling test assesses vitamin B12 absorption by measuring urinary excretion of radiolabeled B12. The nurse should start a 24- to 48-hour urine collection to capture the excreted B12. Methylcellulose, NPO status, and stool collection are not part of the Schilling test protocol.