Nokea
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
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The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
- A. Place an indwelling urinary catheter and measure strict Intake and output.
- B. Initiate bilateral intermittent sequential pneumatic compression devices.
- C. Administer aspirin to prevent further det formation and platelet dumping.
- D. Obtain a focused history to determine recent bleeding and use of anticoagulants.
Correct Answer: D
Rationale: A focused history assesses for stroke risk factors like anticoagulant use, critical for managing neurological symptoms.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?
- A. Surgical consent form is not signed.
- B. Client's pulse oximeter reading is 96%.
- C. Preoperative chest x-ray report is not available.
- D. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L).
Correct Answer: D
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, risking cardiac arrhythmias during surgery, requiring immediate correction.
The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
- A. First voided specimen in the morning.
- B. A clean catch specimen.
- C. Any specimen voided after drinking adequate fluids.
- D. A 24-hour specimen.
Correct Answer: B
Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.
A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
- A. Initiate a referral for ophthalmic evaluation as soon as possible.
- B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve
- C. Instruct the client to rest, and report to the emergency department if eye pain develops.
- D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.