Nokea
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?
- A. Presence of blood in stools
- B. Oozing liquid stool
- C. Continuous rumbling flatulence
- D. Absence of bowel movements
Correct Answer: B
Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.
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The client is receiving discharge teaching for heart failure. Which statement made by the client indicates a need for further teaching?
- A. I will weigh myself daily and report any significant weight gain to my healthcare provider.
- B. I will limit my sodium intake to help manage my heart failure.
- C. I will take my medications as prescribed by my healthcare provider.
- D. I will stop taking my medications if I feel better.
Correct Answer: D
Rationale: Choice D is the correct answer because stopping medications when feeling better can be harmful in heart failure. It is essential to complete the full course of medication as prescribed by the healthcare provider to effectively manage heart failure. Choices A, B, and C demonstrate good understanding and compliance with heart failure management strategies, such as monitoring weight, restricting sodium intake, and adhering to prescribed medications, respectively.
The nurse is caring for a client with a chest tube. Which of these assessments is a priority?
- A. Assessing for subcutaneous emphysema
- B. Assessing for signs of infection at the insertion site
- C. Monitoring the client's respiratory status
- D. Checking the chest tube for kinks or occlusions
Correct Answer: B
Rationale: Assessing for signs of infection at the insertion site is the priority when caring for a client with a chest tube. Infection at the insertion site can lead to serious complications such as empyema or sepsis. Monitoring respiratory status is essential but assessing for infection takes precedence to prevent immediate harm. Assessing for subcutaneous emphysema is important but not the priority unless it compromises respiratory function. Checking the chest tube for kinks or occlusions is crucial for proper drainage but is not the priority when infection is a concern.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. Abdominal x-ray
- B. Auscultation
- C. Flushing tube with saline
- D. Aspiration for gastric contents
Correct Answer: D
Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.
A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?
- A. Sodium
- B. Potassium
- C. Phosphate
- D. Albumin
Correct Answer: B
Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct Answer: D
Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.