Nokea
The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid
- B. Encourage the client to discuss his or her feelings
- C. Administer opioid narcotic medications for pain management
- D. Assist the client out of bed to sit in the chair twice daily
Correct Answer: D
Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.
You may also like to solve these questions
A nurse is reviewing the laboratory results for a client with a history of atherosclerosis and notes elevated cholesterol levels. Which statement by the client indicates the nurse should plan follow-up instruction on a low-cholesterol diet?
- A. ''I take an omega-3 supplement daily.''
- B. ''I cook my food with canola oil.''
- C. ''I eat three eggs for breakfast each morning.''
- D. ''I flavor my meat with lemon juice.''
Correct Answer: C
Rationale: The correct answer is C. Eating three eggs daily increases cholesterol intake, which could exacerbate atherosclerosis. Choice A is incorrect because taking an omega-3 supplement can actually help reduce cholesterol levels. Choice B is incorrect as canola oil is a healthier choice compared to saturated fats. Choice D is incorrect since flavoring meat with lemon juice does not significantly impact cholesterol levels.
A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?
- A. 32-year-old with diarrhea for 6 hours
- B. 2-year-old with 1 wet diaper in 24 hours
- C. 40-year-old with abdominal cramping
- D. 10-year-old who is nauseated
Correct Answer: B
Rationale: In cases of food poisoning, a 2-year-old with reduced urine output is a critical finding indicating dehydration, requiring immediate attention to prevent complications. The reduced urine output is a sign of decreased fluid intake or increased fluid loss, putting the child at high risk for dehydration. This client should be seen first to assess hydration status, initiate necessary interventions, and prevent further complications. While the other symptoms presented by the other clients are concerning, the 2-year-old's decreased urine output poses the most immediate threat to their well-being.
When is Aspirin most effective when taken?
- A. On an empty stomach with cold water
- B. On a full stomach after a meal
- C. With a glass of fruit juice
- D. First thing in the morning
Correct Answer: A
Rationale: Aspirin is best absorbed on an empty stomach to maximize its effectiveness. Taking it with cold water helps to enhance absorption. Choice B is incorrect as taking aspirin on a full stomach may reduce its absorption. Choice C is incorrect as fruit juice can sometimes interact with medications. Choice D is incorrect as taking aspirin first thing in the morning may not optimize its absorption.
What is the combat health support system in the field designed to do?
- A. Provide evacuation to the far rear for treatment and delay return to duty
- B. Project, sustain, and protect the health of the soldier in war and operations other than war
- C. Provide rearward evacuation and reassignment
- D. Provide far rear area care and delayed return to duty
Correct Answer: B
Rationale: The correct answer is B. The combat health support system in the field is designed to project, sustain, and protect the health of soldiers in both war and operations other than war. Choice A is incorrect because the system is not primarily focused on providing evacuation to the far rear for treatment, but rather on overall health support. Choice C is incorrect as it only mentions rearward evacuation and reassignment, which is a limited scope compared to the comprehensive support provided by the system. Choice D is incorrect as it narrowly focuses on far rear area care and delayed return to duty, missing the broader aspects of health support and protection.
In supply and equipment management, what is the FIRST step in the procurement process?
- A. Keep hand receipts up to date
- B. Establish requirements
- C. Requisition supplies and equipment through the proper channels
- D. Properly receive, inspect, and store required items
Correct Answer: B
Rationale: The correct answer is B: Establish requirements. In the procurement process, the initial step involves determining and establishing the requirements for the supplies and equipment needed. This step is crucial as it sets the foundation for the entire procurement process by outlining the specific needs and specifications. Choice A, 'Keep hand receipts up to date,' is not the first step but rather a later administrative task. Choice C, 'Requisition supplies and equipment through the proper channels,' comes after establishing requirements. Choice D, 'Properly receive, inspect, and store required items,' is the final step in the procurement process, focusing on the physical receipt and handling of the procured items.