Nokea
Warm oatmeal (Aveeno) baths are ordered for a client with cancer of the pancreas. What is the chief purpose of this procedure for this client?
- A. Relief of paralytic ileus
- B. Alleviation of pruritus associated with jaundice
- C. Relief of bloating and fullness after eating
- D. Reducing the fever associated with the disease
Correct Answer: B
Rationale: Oatmeal baths alleviate pruritus caused by jaundice, a common symptom in pancreatic cancer due to bile salt accumulation.
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The nurse is caring for a client diagnosed with GERD. Which nursing interventions should be implemented?
- A. Place the client prone in bed and administer nonsteroidal anti-inflammatory medications.
- B. Have the client remain upright at all times and walk for 30 minutes three (3) times a week.
- C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals.
- D. Elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client.
Correct Answer: D
Rationale: Elevating the head of the bed prevents reflux during sleep, and lifestyle modifications (e.g., avoiding trigger foods, not lying down after meals) are key to managing GERD. Prone positioning worsens reflux, remaining upright at all times is impractical, and right lateral positioning is less effective than head elevation.
The client is four (4) hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse?
- A. Absent bowel sounds in all four (4) quadrants.
- B. The T-tube has 60 mL of green drainage.
- C. Urine output of 100 mL in the past three (3) hours.
- D. Refusal to turn, deep breathe, and cough.
Correct Answer: D
Rationale: Refusal to turn, deep breathe, and cough increases the risk of atelectasis and pneumonia post-surgery, requiring immediate intervention. Absent bowel sounds, T-tube drainage, and urine output are expected at this stage.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
Which blood test results would confirm a diagnosis of appendicitis?
- A. WBC of 13,000
- B. RBC of 4.5 million
- C. Platelet count of 300,000
- D. Positive heterophil antibody test
Correct Answer: A
Rationale: An elevated WBC count (e.g., 13,000) indicates inflammation, supporting an appendicitis diagnosis. Normal RBC and platelet counts are not specific, and a heterophil antibody test is for infectious mononucleosis.
Following a hemorrhoidectomy, the nurse is instructing the client in self-care. Which statement is especially important to include in these instructions?
- A. Wash the anal area with water after defecation and pat it dry.'
- B. Gently wipe the anal area after defecation from back to front.'
- C. Do not drink more than three glasses of fluid per day until after you have had the first bowel movement.'
- D. When you first feel the need to defecate, call me and I will give you the enema the doctor has ordered.'
Correct Answer: A
Rationale: Washing and patting dry promotes hygiene and healing post-hemorrhoidectomy, reducing irritation.