Nokea
The nurse is preparing the client for a fiberoptic colonoscopy for colon polyps. Which task can be delegated to the unlicensed assistive personnel (UAP)?
- A. Administer the polyethylene glycol electrolyte lavage solution.
- B. Explain to the client why this morning's breakfast is withheld.
- C. Start an intravenous site with 0.9% normal saline fluid.
- D. Administer a cleansing enema until the return is clear.
Correct Answer: D
Rationale: Administering a cleansing enema is within the UAP’s scope with training. Administering solutions, explaining procedures, and starting IVs require RN skills.
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The 70-year-old client is admitted to the medical unit diagnosed with acute diverticulitis. Which interventions should the nurse implement? Select all that apply.
- A. Tell the client not to eat or drink.
- B. Start an intravenous line.
- C. Assess the client for abdominal tenderness.
- D. Have the dietitian consult for a low-residue diet.
- E. Place the client on bedrest with bathroom privileges.
Correct Answer: A,B,C,E
Rationale: NPO status, IV line, abdominal assessment, and bedrest manage acute diverticulitis by resting the bowel and monitoring complications. Low-residue diets are for stable phases.
Which assessment data indicate to the nurse the client's gastric ulcer has perforated?
- A. Complaints of sudden, sharp, substernal pain.
- B. Rigid, boardlike abdomen with rebound tenderness.
- C. Frequent, clay-colored, liquid stool.
- D. Complaints of vague abdominal pain in the right upper quadrant.
Correct Answer: B
Rationale: A rigid, boardlike abdomen with rebound tenderness indicates peritonitis, a common complication of ulcer perforation due to leakage of gastric contents into the peritoneal cavity. Substernal pain, clay-colored stools, and vague pain are less specific.
The nurse is preparing to hang a new bag of total parenteral nutrition for a client with an abdominal perineal resection. The bag has 1,500 mL of 50% dextrose, 10 mL of trace elements, 20 mL of multivitamins, 20 mL of potassium chloride, and 500 mL of lipids. The bag is to infuse over the next 24 hours. At what rate should the nurse set the pump?
Correct Answer: 83 mL/hr
Rationale: Total volume = 1,500 + 10 + 20 + 20 + 500 = 2,050 mL. Infusion over 24 hours: 2,050 ÷ 24 = 85.42 mL/hr, rounded to 83 mL/hr for pump settings.
The nurse at the scene of a knife fight is caring for a young man who has a knife in his abdomen. Which action should the nurse implement?
- A. Stabilize the knife.
- B. Remove the knife gently.
- C. Turn the client on the side.
- D. Apply pressure to the insertion site.
Correct Answer: A
Rationale: Stabilizing the knife prevents further internal damage until surgical intervention. Removing it, turning the client, or applying pressure risks worsening bleeding.
During a health promotion seminar for senior citizens, a participant asks the nurse to discuss symptoms of gastric cancer. Which statement should be the basis for the nurse’s response?
- A. Cancers that do not penetrate the gastric muscular layer are asymptomatic in the majority of clients.
- B. Pain from early gastric cancer lesions cannot be reduced by over-the-counter (OTC) histamine receptor antagonists.
- C. Unexplained weight gain and increased body mass index (BMI) are early symptoms of gastric cancer.
- D. Anemia is uncommon in gastric cancer, but if it occurs, it is likely due to the effects of aging.
Correct Answer: A
Rationale: A. Eighty percent of clients with early gastric cancer do not have symptoms. B. Pain caused by gastric cancer can be alleviated by OTC histamine receptor antagonists. C. Weight loss and anemia are common symptoms, not weight gain and increased BMI. D. Anemia occurs from malabsorption and nutritional deficiencies, not the effects of aging.