Nokea
Which intervention promotes comfort post-cystectomy?
- A. Encourage deep breathing.
- B. Restrict all fluids.
- C. Keep in supine position.
- D. Administer IV antibiotics.
Correct Answer: A
Rationale: Deep breathing prevents respiratory complications and promotes comfort.
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On the second day following an abdominal perineal resection, the nurse notes that the wound edges aren't approximated and one half the incision has torn apart. The nurse should immediately take what action?
- A. Flush the wound with sterile water.
- B. Apply an abdominal binder.
- C. Cover the wound with a sterile dressing moistened with normal saline.
- D. Apply strips of tape.
Correct Answer: C
Rationale: Covering the wound with a sterile dressing moistened with normal saline protects the open wound from infection and keeps it moist until further medical evaluation. Flushing, applying a binder, or using tape are inappropriate without addressing the dehiscence first. CN: Physiological adaptation; CL: Synthesize
The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.
What is the purpose of sodium polystyrene sulfonate in acute renal failure?
- A. Lower blood pressure.
- B. Reduce serum potassium.
- C. Increase urine output.
- D. Correct acidosis.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate removes potassium from the body, treating hyperkalemia.
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home?
- A. Using enemas to relieve constipation.
- B. Decreasing fluid intake to increase the formed consistency of the stool.
- C. Eating a high-fiber diet when symptomatic with diverticulitis.
- D. Refraining from straining and lifting activities.
Correct Answer: D
Rationale: Refraining from straining and lifting activities prevents increased intra-abdominal pressure, reducing the risk of diverticulitis complications. Enemas, decreased fluid, or high-fiber diets during acute symptoms can worsen the condition. CN: Physiological adaptation; CL: Synthesize
The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINHAL).
- C. An online nursing textbook.
- D. The online policy and procedure manual at the health care agency.
Correct Answer: A
Rationale: The Cochrane Library provides high-quality, evidence-based systematic reviews, making it the most reliable resource for developing standards of care.