Nokea
Which intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct Answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.
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A client takes an antidepressant and oral contraceptives. Which herbal supplement should the nurse educate the client about as a potential drug-herb interaction?
- A. Iron supplement
- B. Garlic
- C. Green tea
- D. St. John's Wort
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals
- B. Explain the need to decrease intake of flatus-forming foods
- C. Teach the client how to perform gentle perianal care
- D. Encourage the client to see a psychologist
Correct Answer: B
Rationale: The correct answer is B. Decreasing the intake of flatus-forming foods can help reduce symptoms of bloating and discomfort in IBS. This intervention focuses on dietary modifications that can positively impact the client's condition. Instructing the client to avoid drinking fluids with meals (choice A) may not directly address the underlying cause of IBS symptoms. Teaching perianal care (choice C) is important for hygiene but does not directly address IBS symptoms. Encouraging the client to see a psychologist (choice D) may be beneficial for managing stress or anxiety associated with IBS but does not directly target symptom reduction through dietary changes.
What intervention would be the most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The most important intervention for a client with a left nephrectomy is to assess the intravenous fluids for rate and volume. After nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Changing the surgical dressing daily, monitoring medication levels, and tracking meal intake are also important aspects of care but not as critical as ensuring adequate intravenous fluid management post-surgery.
The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive?
- A. Bone marrow transplant
- B. Splenectomy
- C. Frequent blood transfusions
- D. Liver biopsy
Correct Answer: B
Rationale: The correct answer is B: Splenectomy. Splenectomy is the treatment of choice for hereditary spherocytosis as it helps prevent hemolysis and improve anemia. Removing the spleen reduces the destruction of the abnormal red blood cells. Choice A, Bone marrow transplant, is not a standard treatment for hereditary spherocytosis. Choice C, Frequent blood transfusions, may be used to manage anemia in some cases but is not the primary treatment for hereditary spherocytosis. Choice D, Liver biopsy, is not a treatment for hereditary spherocytosis; it is a procedure used to diagnose liver conditions, not related to this hematologic disorder.
Which nutrient deficiency is most likely to be seen in patients with chronic alcoholism?
- A. Vitamin C
- B. Vitamin D
- C. Vitamin B12
- D. Vitamin B1
Correct Answer: D
Rationale: In patients with chronic alcoholism, the most likely nutrient deficiency is Vitamin B1 (thiamine), not Vitamin B12. Chronic alcoholism often leads to Vitamin B1 deficiency, causing conditions like Wernicke's encephalopathy. While other vitamin deficiencies can also occur in chronic alcoholism, such as Vitamin C and Vitamin D, Vitamin B1 deficiency is more commonly associated with alcoholism.