Nokea
The nurse is caring for the client to manage and decrease the sensation of nausea. Which nonpharmacological intervention should the nurse recommend?
- A. Sipping tea made from gingerroot
- B. Changing positions more rapidly
- C. Decreasing intake of solid food
- D. Playing stimulating classical music
Correct Answer: A
Rationale: A. Ginger has demonstrated antiemetic properties as well as analgesic and sedative effects on GI motility. B. Avoidance of sudden changes in position and decreasing activity are recommended to control nausea. C. All food should be stopped when nausea is present to prevent stomach stretching and stimulation of the afferent nerve fibers. D. A quiet, calm environment, rather than one that is stimulating, is recommended to decrease nausea.
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The nurse has administered an antibiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. pylori. Which data would indicate to the nurse the medications are effective?
- A. A decrease in alcohol intake.
- B. Maintaining a bland diet.
- C. A return to previous activities.
- D. A decrease in gastric distress.
Correct Answer: D
Rationale: A decrease in gastric distress (e.g., epigastric pain) indicates effective treatment of H. pylori and ulcer healing. Lifestyle changes like reduced alcohol or bland diets support treatment but are not direct indicators of medication efficacy.
The nurse is preparing to administer the initial dose of an aminoglycoside antibiotic to the client diagnosed with acute diverticulitis. Which intervention should the nurse implement?
- A. Obtain a serum trough level.
- B. Ask about drug allergies.
- C. Monitor the peak level.
- D. Assess the vital signs.
Correct Answer: B
Rationale: Checking for drug allergies before administering an aminoglycoside prevents allergic reactions, a critical safety step. Trough and peak levels are monitored later, and vital signs are routine but not specific to the initial dose.
The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? Select all that apply.
- A. Walk for 30 minutes three (3) times a day.
- B. Determine situations that initiate eating behavior.
- C. Weigh at the same time every day.
- D. Limit sodium in the diet.
- E. Refer to a weight support group.
Correct Answer: A,B,C,E
Rationale: Walking, identifying eating triggers, consistent weighing, and support groups promote sustainable weight loss. Sodium restriction is less critical unless hypertension is present.
The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis?
- A. A 60-year-old male with a sedentary lifestyle.
- B. A 72-year-old female with multiple childbirths.
- C. A 63-year-old female with hemorrhoids.
- D. A 40-year-old male with a family history of diverticulosis.
Correct Answer: A
Rationale: Diverticulosis is more common in older adults with sedentary lifestyles, which contribute to constipation and increased colonic pressure. Childbirth, hemorrhoids, and family history are less direct risk factors.
The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
- A. Avoid rectal temperatures.
- B. Use only a soft toothbrush.
- C. Monitor the platelet count.
- D. Use small-gauge needles.
- E. Assess for asterixis.
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.