Nokea
The nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?
- A. Provide a diet that is low in residue
- B. Check the colostomy bag for stool amount
- C. Assess the perineal dressing for drainage
- D. Encourage the client to see the colostomy site
Correct Answer: C
Rationale: The perineal incision must be examined frequently to assess for drainage and the need for dressing changes.
You may also like to solve these questions
The nurse is preparing the postoperative nursing care plan for the client recovering from a hemorrhoidectomy. Which intervention should the nurse implement?
- A. Establish rapport with the client to decrease embarrassment of assessing site.
- B. Encourage the client to lie in the lithotomy position twice a day.
- C. Milk the tube inserted during surgery to allow the passage of flatus
- D. Digitally dilate the rectal sphincter to express old blood.
Correct Answer: A
Rationale: Establishing rapport reduces embarrassment during perianal assessments, promoting comfort post-hemorrhoidectomy. Lithotomy position is not standard for recovery.
The occupational health nurse observes the chief financial officer eat large lunch meals. The client disappears into the restroom after a meal for about 20 minutes. Which observation by the nurse would indicate the client has bulimia?
- A. The client jogs two (2) miles a day.
- B. The client has not gained weight.
- C. The client's teeth are a green color.
- D. The client has smooth knuckles.
Correct Answer: B
Rationale: Maintaining normal weight despite large meals and purging (suggested by restroom visits) is characteristic of bulimia. Jogging, green teeth, and smooth knuckles are less specific.
The client diagnosed with chronic pancreatitis is concerned about pain control. The nurse explains that the initial plan for chronic pancreatic pain control involves the administration of which of the following?
- A. Opioid analgesics, such as morphine sulfate
- B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Pancreatic enzymes with H2 blocker medications
- D. Injection of medication directly into the nerves
Correct Answer: C
Rationale: A. Opioid analgesics may be prescribed if pancreatic enzymes do not relieve pain. B. NSAIDs, such as ibuprofen, may be used to treat chronic pancreatic pain, but they are not the initial treatment and are usually not sufficient to control the pain. C. The initial pain control measures include exogenous pancreatic enzymes because pancreatic stimulation by food is thought to cause pain. Pancreatic enzymes are coupled with H2 blockers, which block the action of histamine on parietal cells in the stomach. H2 blockers are used because gastric acid destroys the lipase needed to break down fats. D. A nerve block relieves pain in about 50 percent of people who undergo the procedure, but this is not the initial measure for pain control.
A distal pancreatectomy and splenectomy is performed on a client with cancer of the pancreas. He is returned to his room postoperatively. The client is sleepy but can answer simple questions appropriately. His dressing is dry and intact. Vital signs are within normal limits. Which of the following nursing measures must be done before the nurse leaves the room?
- A. Inform his wife that he has returned to his room.
- B. Check to see if the indwelling urinary catheter bag is correctly attached to the bed frame.
- C. Assess to be sure he is not experiencing any discomfort.
- D. Put all four side rails in the high position.
Correct Answer: D
Rationale: Raising all four side rails ensures safety for a sleepy postoperative client, preventing falls.
The nurse writes the problem 'imbalanced nutrition: less than body requirements' for the client diagnosed with hepatitis. Which intervention should the nurse include in the plan of care?
- A. Provide a high-calorie intake diet.
- B. Discuss total parenteral nutrition (TPN).
- C. Instruct the client to decrease salt intake.
- D. Encourage the client to increase water intake.
Correct Answer: A
Rationale: A high-calorie diet addresses malnutrition and weight loss common in hepatitis, supporting recovery. TPN is invasive, salt restriction is unrelated, and water intake is less critical.