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The student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:
- A. Swallow foods while leaning forward.
- B. Omit fluids at mealtimes.
- C. Eat meals sitting upright.
- D. Avoid soft and semisoft foods.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse evaluates the client's stoma during the initial post-op period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous
- B. The stoma is dark red to purple
- C. The stoma oozes a small amount of blood
- D. The stoma does not expel stool
Correct Answer: B
Rationale: A dark red to purple stoma may indicate compromised blood flow or ischemia, which requires immediate medical attention. This color change could be a sign of inadequate blood supply to the stoma tissue, leading to tissue damage or necrosis. Reporting this observation promptly is crucial to prevent further complications. Choices A, C, and D are not indicative of immediate medical concern. A slightly edematous stoma, oozing a small amount of blood, or not expelling stool may not be uncommon findings during the initial post-op period and can be managed without urgent intervention.
You're caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?
- A. 100 ml
- B. 500 ml
- C. 1500 ml
- D. 5000 ml
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Rob is a 46 y.o. admitted to the hospital with a suspected diagnosis of Hepatitis B. He's jaundiced and reports weakness. Which intervention will you include in his care?
- A. Regular exercise.
- B. A low-protein diet.
- C. Allow patient to select his meals.
- D. Rest period after small, frequent meals.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client's ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?
- A. Heart failure
- B. DVT
- C. Hypokalemia
- D. Hypocalcemia
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You are developing a careplan on Sally, a 67 y.o. patient with hepatic encephalopathy. Which of the following do you include?
- A. Administering a lactulose enema as ordered.
- B. Encouraging a protein-rich diet.
- C. Administering sedatives, as necessary.
- D. Encouraging ambulation at least four times a day.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.