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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A nurse is reinforcing discharge teaching with a client who has acute pancreatitis and a prescription for fat-soluble vitamin supplements. Which of the following supplements should the nurse include in the teaching?
- A. Vitamin A
- B. Vitamin B1
- C. Vitamin C
- D. Vitamin B12
Correct Answer: A
Rationale: The correct answer is Vitamin A. Fat-soluble vitamins essential for patients with pancreatitis include A, D, E, and K, aiding in proper nutrient absorption. Vitamin B1 (Choice B), also known as thiamine, is a water-soluble vitamin and not a fat-soluble one. Vitamin C (Choice C) is another water-soluble vitamin and not a fat-soluble one. Vitamin B12 (Choice D) is also a water-soluble vitamin and not one of the fat-soluble vitamins crucial for patients with pancreatitis.
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.
When another nurse enters the room in response to a call, after checking the client's pulse and respirations during CPR on an adult in cardiopulmonary arrest, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct Answer: C
Rationale: The correct answer is to participate in compressions or breathing. This is essential to ensure continuous and effective CPR. Relieving the nurse performing CPR (Choice A) is not recommended as it can interrupt the life-saving procedure. Going to get the code cart (Choice B) may be necessary in certain situations but should not take precedence over providing immediate assistance in CPR. Validating the client's advanced directive (Choice D) is not the primary role in this scenario where urgent action is needed to support the client's circulation and breathing.
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.
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).