Nokea
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
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What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply.
- A. Cut around blood stains to remove clothing.
- B. Place each item of clothing in a separate paper bag.
- C. Allow clothing to dry.
- D. Refrain from documenting client statements.
- E. Place bullets in a sterile container.
Correct Answer: B
Rationale: To preserve forensic evidence, clothing should be placed in separate paper bags to prevent cross-contamination. Cutting around blood stains or placing bullets in sterile containers may damage evidence, and documentation of statements is necessary for legal purposes.
What should the nurse teach a client with Parkinson's about fall prevention?
- A. Use a walker if unsteady.
- B. Avoid all physical activity.
- C. Wear tight shoes.
- D. Keep lights dimmed.
Correct Answer: A
Rationale: Using a walker if unsteady helps prevent falls in Parkinson's patients with gait instability.
The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as
- A. a vesicant drug entering into intradermal tissue.
- B. a non-vesicant drug entering subcutaneous tissue.
- C. a vesicant drug entering into subcutaneous tissue.
- D. a vesicant drug entering the muscle by injection.
Correct Answer: B
Rationale: Infiltration involves non-vesicant fluid leaking into subcutaneous tissue, causing swelling and discomfort.
Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will:
- A. Demonstrate appropriate use of analgesics to control pain.
- B. Explain the rationale for eliminating alcohol from the diet.
- C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months.
- D. Eliminate contact sports from his or her lifestyle.
Correct Answer: B
Rationale: Eliminating alcohol is critical for clients with peptic ulcer disease, as it irritates the gastric mucosa and can exacerbate symptoms. The other options are less directly related to the management of peptic ulcer disease.