Nokea
The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
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The client developed a paralytic ileus after abdominal surgery. Which intervention should the nurse include in the plan of care?
- A. Administer a laxative of choice.
- B. Encourage the client to increase oral fluids.
- C. Encourage the client to take deep breaths.
- D. Maintain a patent nasogastric tube.
Correct Answer: D
Rationale: Maintaining a patent NG tube decompresses the bowel in paralytic ileus, preventing complications. Laxatives and oral fluids are contraindicated, and deep breathing is unrelated.
The nurse is reviewing the health history of the client receiving treatment for hemorrhoids. Which information, related to the development of hemorrhoids, should the nurse expect to find in the client’s medical history?
- A. Body mass index of 18
- B. Chronic constipation
- C. Nulliparous female
- D. Works as a salesperson
- E. Taking iron supplements
Correct Answer: B, E
Rationale: Clients who are thin (BMI = 18) would have a decreased risk of hemorrhoid development. Obesity is a risk factor for hemorrhoid development. B. Prolonged constipation is a risk factor for development of hemorrhoids. C. Since pregnancy is a common cause of constipation, nulliparous women would have a decreased risk of hemorrhoid development. D. Sedentary rather than active occupations have an increased risk of hemorrhoid development. E. Iron supplements can lead to constipation and straining, which can precipitate hemorrhoid development.
An adult is being treated for a peptic ulcer. The physician has prescribed cimetidine (Tagamet) for which reason?
- A. It blocks the secretion of gastric hydrochloric acid.
- B. It coats the gastric mucosa with a protective membrane.
- C. It increases the sensitivity of histamine (H2) receptors.
- D. It neutralizes acid in the stomach.
Correct Answer: A
Rationale: Cimetidine, an H2 receptor blocker, reduces gastric acid secretion, aiding peptic ulcer healing.
The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
The nurse is caring for the client diagnosed with cirrhosis. After completing discharge education, the nurse recognizes the need for further teaching when the client makes which statement?
- A. “My cirrhosis was caused from too much alcohol; I plan to stop drinking.”
- B. “I need to rest more; I plan on only going to work on a part-time basis.”
- C. “Propranolol has been ordered to decrease my blood pressure.”
- D. “Furosemide will help to reduce the amount of abdominal fluid.”
Correct Answer: C
Rationale: A. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client’s diet. B. Rest may enable the liver to restore itself and should be encouraged. C. Although propranolol (Inderal) does decrease BP, it is not ordered for this purpose in treating cirrhosis. Prophylactic treatment with a nonselective beta blocker like propranolol has been shown to reduce the risk of bleeding from esophageal varices and to reduce bleeding-related deaths. D. Furosemide (Lasix) is used in combination with potassium-sparing diuretics to decrease ascites.