Nokea
What advice should be given to a client experiencing constipation?
- A. Encourage the client to drink water frequently
- B. Increase dietary fiber to relieve constipation
- C. Administer a laxative to relieve discomfort
- D. Encourage the client to increase physical activity
Correct Answer: B
Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.
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A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?
- A. History of gastrointestinal bleeding
- B. Prothrombin time of 12 seconds
- C. Platelet count of 180,000/mm³
- D. Creatinine level of 1.0 mg/dL
Correct Answer: A
Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.
A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?
- A. Turn the client onto their left side
- B. Irrigate the NG tube with sterile water
- C. Increase the suction pressure to relieve the blockage
- D. Remove the NG tube and replace it with a new one
Correct Answer: B
Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.
What is the primary intervention for sepsis?
- A. Administer IV antibiotics
- B. Monitor blood pressure
- C. Administer fluids
- D. All of the above
Correct Answer: D
Rationale: The primary intervention for sepsis involves a multifaceted approach, including administering IV antibiotics to address the underlying infection and administering fluids to stabilize the patient's hemodynamic status. Monitoring blood pressure is important in the management of sepsis, but it is not the sole primary intervention. Therefore, the correct answer is 'All of the above' as it encompasses the comprehensive approach required for effective sepsis management.
A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?
- A. Rectal
- B. Axillary
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.
A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?
- A. Use a bed exit alarm to notify staff of attempts to leave the bed
- B. Raise all four side rails for safety
- C. Encourage frequent ambulation with assistance
- D. Use restraints to prevent the client from getting out of bed
Correct Answer: A
Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.