Nokea
Which intervention should the nurse implement specifically for the client in end-stage liver failure who is experiencing hepatic encephalopathy?
- A. Assess the client's neurological status.
- B. Prepare to administer a loop diuretic.
- C. Check the client's stool for blood.
- D. Assess for an abdominal fluid wave.
Correct Answer: A
Rationale: Neurological assessment monitors hepatic encephalopathy progression (e.g., confusion, asterixis), guiding treatment. Diuretics, stool checks, and fluid wave assessments are less specific.
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Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods?
- A. An antidiarrheal medication.
- B. An aminoglycoside antibiotic.
- C. An antitoxin medication.
- D. An ACE inhibitor medication.
Correct Answer: C
Rationale: Botulism is treated with antitoxin to neutralize the toxin and prevent further paralysis. Antidiarrheals, antibiotics, and ACE inhibitors are inappropriate for botulism.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.
The nurse writes a psychosocial problem of 'risk for altered sexual functioning related to new colostomy.' Which intervention should the nurse implement?
- A. Tell the client there should be no intimacy for at least three (3) months.
- B. Ensure the client and significant other are able to change the ostomy pouch.
- C. Demonstrate with charts possible sexual positions for the client to assume.
- D. Teach the client to protect the pouch from becoming dislodged during sex.
Correct Answer: D
Rationale: Teaching pouch protection during sex addresses practical concerns, supporting sexual function and confidence. A three-month intimacy ban is unnecessary, pouch changing is unrelated to sexual function, and charts may be less practical.
The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included in the presentation?
- A. Wear a high-filtration mask when around chemicals.
- B. Eat several servings of cruciferous vegetables daily.
- C. Take a multiple vitamin every day.
- D. Do not engage in high-risk sexual behaviors.
Correct Answer: B
Rationale: Cruciferous vegetables (e.g., broccoli, cauliflower) are high in fiber and antioxidants, which may reduce colon cancer risk. Masks, vitamins, and sexual behaviors are less directly linked to colon cancer prevention.
The nurse identifies the problem of 'fluid volume deficit' for a client diagnosed with gastritis. Which intervention should be included in the plan of care?
- A. Obtain permission for a blood transfusion.
- B. Prepare the client for total parenteral nutrition.
- C. Monitor the client's lung sounds every shift.
- D. Assess the client's intravenous site.
Correct Answer: D
Rationale: Assessing the IV site ensures proper fluid administration to correct fluid volume deficit in gastritis. Blood transfusion, TPN, and lung sounds are not directly related.