Nokea
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
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Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
- A. Dehydration
- B. Atelectasis
- C. Wound infection
- D. Bladder infection
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.