Nokea
The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
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Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
- A. A 36-year-old client with abdominal pain
- B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
- C. A 76-year-old client with terminal cancer
- D. An 84-year-old client with severe arthritis
Correct Answer: B
Rationale: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.
The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.
- A. A client who had rectal surgery and a post-operative abscess
- B. A child who has pneumonia
- C. An older client who is post-myocardial infarction (MI)
- D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia
- E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)
Correct Answer: A,D,E
Rationale: Rectal temperature is contraindicated in rectal surgery/abscess (due to trauma risk), neutropenia (infection risk), and DIC (bleeding risk). Pneumonia and post-MI do not contraindicate rectal measurement.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is reviewing the vital signs of a client admitted with atrial fibrillation. The client's vital signs are: T 37.5°C (99.6°F), P 88 and irregular, RR 20, BP 90/56 mmHg, pulse oximetry reading 96% on room air. The nurse should immediately address which vital sign?
- A. Temperature
- B. Blood pressure
- C. Respiratory rate
- D. Pulse
Correct Answer: B
Rationale: Low BP (90/56 mmHg) indicates potential hemodynamic instability, requiring immediate attention in atrial fibrillation. Temperature, respiratory rate, and pulse are less critical.