Nokea
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
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Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis?
- A. How many years have you been drinking alcohol?
- B. Have you completed an advance directive?
- C. When did you have your last alcoholic drink?
- D. What foods did you eat at your last meal?
Correct Answer: C
Rationale: Recent alcohol consumption can exacerbate liver failure and affect treatment decisions, making it the priority question. Duration of drinking, advance directives, and diet are secondary.
Which diagnostic data should be reported to the health-care provider (HCP) immediately?
- A. The ABG result of pH 7.11, PaCO2 45, HCO3 20, and PaO2 98 for a client diagnosed with type 1 diabetes.
- B. Sodium 137 mEq/L, potassium 4 mEq/L, glucose 120 mg/dL for a client diagnosed with gastroenteritis.
- C. Hemoglobin 9.4 g/dL and hematocrit 29% for a client who received a blood transfusion on the previous shift.
- D. A pulse oximetry reading of 93% for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Correct Answer: A
Rationale: A pH of 7.11 indicates severe acidosis (likely DKA in type 1 diabetes), requiring immediate HCP notification. Normal electrolytes, post-transfusion anemia, and COPD oximetry are less urgent.
The nurse is assessing the client diagnosed with chronic gastritis. Which symptom(s) support this diagnosis?
- A. Rapid onset of midsternal discomfort.
- B. Epigastric pain relieved by eating food.
- C. Dyspepsia and hematemesis.
- D. Nausea and projectile vomiting.
Correct Answer: C
Rationale: Dyspepsia (indigestion) and hematemesis (vomiting blood) are symptoms of chronic gastritis due to mucosal irritation. Midsternal pain, pain relief with food, and projectile vomiting are less typical.
The postanesthesia care nurse is caring for a client who had abdominal surgery and is complaining of nausea. Which intervention should the nurse implement first?
- A. Medicate the client with a narcotic analgesic (IVP).
- B. Assess the nasogastric tube for patency.
- C. Check the temperature for elevation.
- D. Hyperextend the neck to prevent stridor.
Correct Answer: B
Rationale: Assessing NG tube patency ensures it is functioning to prevent nausea from gastric distension. Narcotics may worsen nausea, fever is secondary, and neck hyperextension is irrelevant.
The nurse is developing a plan of care for the client with cirrhosis. Which intervention should be included in the client’s plan of care?
- A. Monitor the client’s blood sugar level.
- B. Place the client on NPO status.
- C. Administer antibiotics every 6 hours.
- D. Encourage ambulation every 4 hours.
Correct Answer: A
Rationale: A. The nurse should prepare to monitor the client’s blood sugar level. The client with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common with cirrhosis, and about 20% to 40% of clients also have diabetes. Hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. B. The client with cirrhosis would not be NPO but should receive a high-protein diet unless hepatic encephalopathy is present. C. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. D. The client with cirrhosis requires rest; thus, ambulation should not be encouraged every 4 hours.