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Which data should the nurse report to the healthcare provider when assessing the oral cavity of an elderly client?
- A. The client's tongue is rough and beefy red.
- B. The client's tonsils are +1 on a grading scale.
- C. The client's mucosa is pink and moist.
- D. The client's uvula rises with the mouth open.
Correct Answer: A
Rationale: A rough, beefy red tongue may indicate vitamin B12 deficiency or glossitis, warranting HCP notification. Normal tonsil size, pink/moist mucosa, and uvula movement are expected findings.
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Following a hemorrhoidectomy, the nurse assesses the client's voiding. What is the reason for this concern?
- A. The client has been NPO before and during surgery.
- B. Urinary retention is frequently seen after a hemorrhoidectomy.
- C. The client has a long history of hemorrhoids, making her prone to voiding problems.
- D. The client had several pregnancies, which can make voiding difficult.
Correct Answer: B
Rationale: Urinary retention is common post-hemorrhoidectomy due to pain and swelling affecting pelvic nerves.
The nurse working in a skilled nursing facility is collaborating with the dietitian concerning the meals of an immobile client. Which foods are most appropriate for this client?
- A. Oatmeal and wheat toast.
- B. Cream of wheat and biscuits.
- C. Cottage cheese and canned peaches.
- D. Tuna on a croissant and applesauce.
Correct Answer: C
Rationale: Cottage cheese and canned peaches are soft, low-fiber, and easy to digest, suitable for an immobile client at risk for constipation. High-fiber options (oatmeal, wheat) may be harder to tolerate.
Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?
- A. Auscultate the client's bowel sounds in all four quadrants.
- B. Palpate the abdominal area for tenderness.
- C. Percuss the abdominal borders to identify organs.
- D. Assess the tender area progressing to nontender.
Correct Answer: B
Rationale: Palpating for tenderness helps identify epigastric pain, a key symptom of peptic ulcer disease, and guides further assessment. Auscultation, percussion, and specific tender-to-nontender assessment are secondary in this context.
Which outcome should the nurse identify for the client scheduled to have a cholecystectomy?
- A. Decreased pain management.
- B. Ambulate first day postoperative.
- C. No break in skin integrity.
- D. Knowledge of postoperative care.
Correct Answer: B
Rationale: Ambulation on the first postoperative day prevents complications like thrombosis and atelectasis. Pain management should increase, skin integrity may be disrupted, and knowledge is a process, not an outcome.
The nurse is caring for a client diagnosed with ulcerative colitis. Which symptom(s) support this diagnosis?
- A. Increased appetite and thirst.
- B. Elevated hemoglobin.
- C. Multiple bloody, liquid stools.
- D. Exacerbations unrelated to stress.
Correct Answer: C
Rationale: Multiple bloody, liquid stools are a hallmark of ulcerative colitis due to mucosal inflammation. Appetite/thirst increase, elevated hemoglobin, and stress-unrelated exacerbations are incorrect.