Nokea
The nurse is caring for the client one 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 an essential nursing intervention postoperatively as it helps promote circulation, prevent complications like blood clots, and aids in the recovery process. Changing the infusion rate of intravenous fluid (Choice A) requires a physician's order and is not an independent nursing intervention. Encouraging the client to discuss feelings (Choice B) is important for emotional support but not as crucial as physical care immediately postoperatively. Administering opioid narcotic medications (Choice C) for pain management should be based on a prescribed schedule and assessment rather than being an independent nursing action.
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The system used at the division level and forward comprises six basic modules. Which module is staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses?
- A. Treatment squad
- B. Area support squad
- C. Medical service squad
- D. Forward surgical team
Correct Answer: D
Rationale: The correct answer is D, Forward Surgical Team (FST). The FST is staffed with two surgeons, two nurse anesthetists, a medical/surgical nurse, two operating room specialists, and two practical nurses. This specialized team is designed to provide immediate surgical care close to the frontline. Choices A, B, and C are incorrect as they do not match the specific composition of personnel described in the question.
Why may patients with hiatal hernia develop anemia?
- A. Iron absorption is reduced
- B. Gastritis may cause bleeding
- C. Iron stores turn over more quickly
- D. Patients have an aversion to foods that are good sources of iron
Correct Answer: B
Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can occur due to the reflux of stomach acid into the esophagus. This gastritis can lead to gastrointestinal bleeding, resulting in anemia. Choice A is incorrect because iron absorption is not necessarily reduced in hiatal hernia. Choice C is incorrect as iron stores turnover rate is not directly related to the development of anemia in this context. Choice D is incorrect as an aversion to iron-rich foods is not a common reason for anemia in patients with hiatal hernia.
The healthcare provider is conducting a respiratory assessment and is determining respirations per minute. Which factor(s) generally affect the character of respirations? Select all that apply.
- A. Anxiety
- B. Exercise
- C. Smoking
- D. A, B
Correct Answer: D
Rationale: Correct! Anxiety and exercise can significantly alter the character of respirations, increasing the rate and depth. Smoking, while harmful to the respiratory system in the long term, does not directly affect the character of respirations like anxiety and exercise do. Therefore, choices C (Smoking) is incorrect. The correct answer is D (A, B).
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.
The nurse teaches the mother of an infant how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions?
- A. Feed the infant with a newborn nipple while holding him in the recumbent position
- B. Clean the suture site with a cotton-tipped swab soaked in Betadine
- C. Place the infant in the prone position after feeding
- D. Feed the infant with a rubber-tipped syringe and burp frequently
Correct Answer: D
Rationale: The correct answer is D because feeding the infant with a rubber-tipped syringe reduces the risk of injury to the surgical site and prevents aspiration. Choice A is incorrect because feeding in the recumbent position can increase the risk of aspiration. Choice B is incorrect as Betadine is not recommended for wound care near the mouth due to its potential toxicity if ingested. Choice C is incorrect because placing the infant in the prone position after feeding can increase the risk of regurgitation and aspiration.