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The nurse is caring for the client with hepatic encephalopathy who is receiving lactulose. Which finding should the nurse expect after the administration of this medication?
- A. An increase in body temperature
- B. Neurological changes, such as confusion
- C. A change in urine specific gravity
- D. A decrease in oral fluid intake
Correct Answer: B
Rationale: A. The client’s temperature will not be affected. B. Elevated serum ammonia levels may cause neurological changes, such as confusion. C. The client’s urine specific gravity will not be affected. D. Oral fluid intake should be encouraged if tolerated by the client.
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The nurse is caring for the client recovering from intestinal surgery. Which assessment finding requires immediate intervention?
- A. Presence of thin, pink drainage in the Jackson Pratt.
- B. Guarding when the nurse touches the abdomen.
- C. Tenderness around the surgical site during palpation.
- D. Complaints of chills and feeling feverish.
Correct Answer: D
Rationale: Chills and feeling feverish suggest infection, a serious postoperative complication requiring immediate intervention. Thin pink drainage, guarding, and tenderness are expected early post-surgery.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
- A. Notify the surgeon immediately.
- B. Instruct the client to splint the incision.
- C. Assess the abdominal wound incision.
- D. Administer pain medication intravenously.
Correct Answer: C
Rationale: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.
The client, admitted with appendicitis, overhears the physician say that the pain has reached McBurney's point. She becomes very frightened and asks the nurse to explain what this means. Which is the best response?
- A. The next time the doctor comes in, we should ask him what he meant by that.'
- B. I've felt that I don't understand the doctor at times either.'
- C. That is the term used to indicate that the pain has traveled to the right lower side.'
- D. McBurney's point refers to severe pain for which surgery is the only treatment.'
Correct Answer: C
Rationale: McBurney's point is the area in the right lower quadrant where appendicitis pain localizes, indicating inflammation of the appendix.
The nurse is preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?
Correct Answer: 83 mL/hr
Rationale: Total volume = 1,500 + 10 + 20 + 20 + 500 = 2,050 mL. Infusion over 24 hours: 2,050 ÷ 24 = 85.42 mL/hr, rounded to 83 mL/hr for pump settings.
The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?
- A. Give morphine sulfate per IV bolus before the first defecation.
- B. Have the client take a sitz bath after each defecation.
- C. Begin high-fiber diet as soon as client can tolerate oral intake.
- D. Position supine with the head of the bed elevated to 30 degrees.
Correct Answer: D
Rationale: A. Pain medication is recommended before the first defecation to avoid straining. B. A sitz bath is encouraged for rectal cleansing after defecation. C. A high-fiber diet prevents constipation. D. After anorectal surgery, the client should be positioned in a side-lying (not supine) position to decrease rectal edema and client discomfort.