Nokea
The nurse measures the amount of bile drainage from a T-tube and records it by which one of the following method:
- A. Adding it to the client's urine output.
- B. Charting it separately on the output record.
- C. Adding it to the amount of wound drainage.
- D. Subtracting it from the total intake for each day.
Correct Answer: B
Rationale: T-tube drainage is bile output and should be recorded separately on the output record (option B) to accurately track fluid loss. Adding it to urine output (A) or wound drainage (C) is incorrect as it represents a distinct type of output. Subtracting it from intake (D) is not a standard practice.
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The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report?
- A. The client with cirrhosis who became confused and disoriented during the night.
- B. The client with acute pancreatitis who is requesting pain medication.
- C. The client who is 1 day postoperative following a cholecystectomy and has a T-tube inserted.
- D. The client with hepatitis B who has questions about his discharge instructions.
Correct Answer: A,B,C,D
Rationale: Confusion in cirrhosis (A) indicates possible hepatic encephalopathy, a priority. Pain in pancreatitis (B) requires prompt relief. Postoperative T-tube monitoring (C) is next. Discharge teaching (D) is lowest priority.
A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client?
- A. Intensity.
- B. Cause.
- C. Aggravating factors.
- D. Location.
Correct Answer: A
Rationale: Pain intensity is the most significant component in assessing bone cancer pain, as it guides the urgency and type of pain management interventions needed.
A client with a hip fracture is using a walker. Which observation indicates incorrect use of the walker?
- A. The client leans forward over the walker.
- B. The client advances the walker before stepping.
- C. The client uses the walker on both sides.
- D. The client keeps elbows slightly bent.
Correct Answer: A
Rationale: Leaning forward over the walker compromises balance and increases fall risk.
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
- A. Dissolves stones.
- B. Relaxes ureter muscles.
- C. Reduces urine output.
- D. Prevents infection.
Correct Answer: B
Rationale: Tamsulosin relaxes ureter muscles, aiding stone passage.
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.