Nokea
The RN overhears the LPN talking with the client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. Which statement made by the LPN should the RN clarify to decrease the client’s anxiety?
- A. “This surgery will prevent you from developing colon cancer.”
- B. “After this surgery you will no longer have ulcerative colitis.”
- C. “After surgery you may not have solid food for several days.”
- D. “You’ll have a permanent ileostomy after having this surgery.”
Correct Answer: D
Rationale: A. The client will not be at risk for colon cancer because with a total colectomy the entire colon is removed. B. Since this surgery removes the total colon, the ulcerative colitis will be cured. C. The client will be unable to eat until peristalsis returns, and then it may take several days before solid foods are tolerated. D. The client will initially have an ileostomy; after the reservoir has healed, the ileostomy will be closed. Knowing that the ileostomy will be temporary is important information for the client to decrease anxiety.
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Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.
The nurse is discharging the client after Billroth II surgery (gastrojejunostomy). To assist the client to control dumping syndrome, which information should the nurse include in the client’s discharge instructions?
- A. Drink plenty of fluids with all your meals.
- B. Eat a high-carbohydrate, low-protein diet
- C. Wait to eat at least 5 hours between meals.
- D. Lie down for 20 to 30 minutes after meals.
Correct Answer: D
Rationale: A. Drinking fluids at mealtime increases the size of the food bolus that enters the stomach. B. Carbohydrates are more rapidly digested than fats and proteins and would cause the food bolus to pass quickly into the intestine, increasing the likelihood that dumping syndrome would occur. Meals high in carbohydrates result in postprandial hypoglycemia, which is considered a variant of dumping syndrome. C. Small, frequent meals are recommended to decrease dumping syndrome. D. Lying down after meals slows the passage of the food bolus into the intestine and helps to control dumping syndrome.
Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
Which diagnostic data should be reported to the health-care provider (HCP) immediately?
- A. The ABG result of pH 7.11, PaCO2 45, HCO3 20, and PaO2 98 for a client diagnosed with type 1 diabetes.
- B. Sodium 137 mEq/L, potassium 4 mEq/L, glucose 120 mg/dL for a client diagnosed with gastroenteritis.
- C. Hemoglobin 9.4 g/dL and hematocrit 29% for a client who received a blood transfusion on the previous shift.
- D. A pulse oximetry reading of 93% for a client diagnosed with chronic obstructive pulmonary disease (COPD).
Correct Answer: A
Rationale: A pH of 7.11 indicates severe acidosis (likely DKA in type 1 diabetes), requiring immediate HCP notification. Normal electrolytes, post-transfusion anemia, and COPD oximetry are less urgent.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.