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The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
- A. Additional potassium will be given IV
- B. Blood for coagulation studies will be drawn
- C. Total parenteral nutrition (TPN) will be started
- D. Serum lipase levels will be evaluated
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) will be started. The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
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A client is waiting to have an intravenous pyelogram (IVP). The most important information to be obtained by the nurse prior to the procedure is
- A. time of the client's last meal
- B. client's allergy history
- C. assessment of the peripheral pulses
- D. results of the blood coagulation studies
Correct Answer: B
Rationale: Intravenous Pyelogram is a dye study that uses an iodine-based contrast. Therefore, the study is contraindicated in clients with allergy to iodine.
Which discharge teaching instructions should the nurse reinforce to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply.
- A. Complete all the antibiotics even if your child is feeling better
- B. Cool liquids and soft diet are recommended
- C. Keep your child home from daycare for at least a week
- D. Replace your child’s toothbrush 24 hours after starting antibiotics
- E. Throat lozenges may soothe your child’s sore throat
Correct Answer: A,B,D
Rationale: Completing antibiotics prevents resistance, cool liquids/soft foods ease swallowing, and replacing the toothbrush prevents reinfection. A week-long daycare exclusion is excessive (24-48 hours post-antibiotics is sufficient), and lozenges are unsafe for a 2-year-old due to choking risk.
The nurse is caring for several clients who have ostomies. Which client will have the most wellformed drainage? The client whose colostomy is in the:
- A. ileum.
- B. ascending colon.
- C. transverse colon.
- D. descending colon.
Correct Answer: D
Rationale: The descending colon absorbs more water, producing well-formed, solid stool compared to the ileum (liquid), ascending colon (semi-liquid), or transverse colon (semi-formed).
A client is admitted with a possible gastric ulcer. Suddenly he calls to the nurse and says, 'It hurts so bad.' The client is pale and diaphoretic. What should the nurse do initially?
- A. Call the physician
- B. Touch the abdomen
- C. Obtain a stool for guaiac
- D. Place the client in a supine position
Correct Answer: A
Rationale: Sudden severe pain with pallor and diaphoresis suggests ulcer perforation, requiring immediate physician notification for urgent intervention.
The role of the incident report in risk management is:
- A. liability protection.
- B. to provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. to discipline staff for errors.
- D. all of the above.
Correct Answer: B
Rationale: Incident reports collect data to analyze and prevent future issues, enhancing safety. They are not for liability protection or staff discipline. Safety and Infection Control