Nokea
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.
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The nurse is administering morning medications at 0730. Which medication should have priority?
- A. A proton pump inhibitor.
- B. A nonnarcotic analgesic.
- C. A histamine receptor antagonist.
- D. A mucosal barrier agent.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) are the mainstay treatment for GERD, reducing acid production and preventing esophageal damage. They should be prioritized over analgesics, histamine receptor antagonists, or mucosal barrier agents, which are less critical for immediate symptom control and healing.
The client is being prepared for discharge after a laparoscopic cholecystectomy. Which intervention should the nurse implement?
- A. Discuss the need to change the abdominal dressing daily.
- B. Tell the client to check the T-tube output every eight (8) hours.
- C. Include the significant other in the discharge teaching.
- D. Instruct the client to stay off clear liquids for two (2) days.
Correct Answer: C
Rationale: Including the significant other ensures support and reinforces discharge teaching for recovery. Daily dressing changes are unnecessary, T-tubes are not used in laparoscopic procedures, and clear liquids are encouraged.
The client complains to the nurse of unhappiness with the health-care provider. Which intervention should the nurse implement next?
- A. Call the HCP and suggest he or she talk with the client.
- B. Determine what about the HCP is bothering the client.
- C. Notify the nursing supervisor to arrange a new HCP to take over.
- D. Explain the client cannot request another HCP until after discharge.
Correct Answer: B
Rationale: Determining the specific issue allows the nurse to address the concern effectively, whether through communication, advocacy, or escalation. Contacting the HCP or supervisor prematurely or dismissing the client’s request is less appropriate.
The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?
- A. White blood cells (WBCs) elevated
- B. Temperature of 101°F (38.3°C)
- C. Bowel sounds are absent
- D. Reports intense abdominal pain
Correct Answer: C
Rationale: A. Elevated WBCs are a symptom of acute diverticulitis. B. Increased temperature is a symptom of acute diverticulitis. C. Clients with intestinal perforation develop paralytic ileus. Bowel sounds would be absent. D. Abdominal pain is a symptom of acute diverticulitis that may worsen with intestinal perforation, but the most significant finding would be absent bowel sounds.
The nurse is preparing a client with Crohn's disease for discharge. Which of the following statements indicates that he needs further teaching?
- A. Stress can make it worse.'
- B. Since I have Crohn's disease, I don't have to worry about colon cancer.'
- C. I realize I shall always have to monitor my diet.'
- D. I understand there is a high incidence of familial occurrence with this disease.'
Correct Answer: B
Rationale: Crohn’s disease increases the risk of colon cancer, so the statement indicates a need for further teaching. The other statements are correct.