Nokea
Which of the following interventions would be the most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?
- A. Encourage the client to ambulate every 2 to 4 hours.
- B. Offer 3 to 4 oz of a carbonated beverage periodically.
- C. Encourage use of a stool softener.
- D. Continue I.V. fluid therapy.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, reducing the risk of paralytic ileus post-renal surgery by promoting gastrointestinal function.
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Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
- A. Rolling the client onto the side.
- B. Sliding the client to move up in bed.
- C. Lifting the client when moving the client up in bed.
- D. Having the client help lift off the bed using a trapeze.
Correct Answer: B
Rationale: Sliding the client can cause shear injuries to the skin, especially in hemiparalysis with reduced sensation. Rolling, lifting, or using a trapeze (if feasible) are safer techniques.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:
- A. Hyperalbuminemia.
- B. Thrombocytopenia.
- C. Hypokalemia.
- D. Hypercalcemia.
Correct Answer: C
Rationale: Crohn's disease with diarrhea can lead to hypokalemia due to potassium loss in stool. Hyperalbuminemia and hypercalcemia are not typical, and thrombocytopenia is less directly related to these symptoms. CN: Physiological adaptation; CL: Analyze
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon.
- C. Empty drainage.
- D. Record the amount in the unit as output on the client's chart.
Correct Answer: C
Rationale: A full portable wound suction unit (e.g., Jackson-Pratt) should be emptied to maintain suction and prevent complications. The drainage is then measured and recorded.
A client with a below-knee amputation is learning to wrap the residual limb. Which technique should the nurse teach?
- A. Wrap loosely to allow air circulation.
- B. Apply the wrap from proximal to distal.
- C. Use a figure-eight pattern.
- D. Secure the wrap with adhesive tape.
Correct Answer: C
Rationale: A figure-eight pattern ensures even pressure and proper shaping for prosthetic fitting.