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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The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a leading cause of acute pancreatitis, so the physician's questions are relevant to determine etiology (A). Options B, C, and D are inaccurate or dismissive of the client's concerns.
The nurse is developing a discharge plan about home care with a client who has lymphoma. The nurse should emphasize which of the following?
- A. Use analgesics as needed.
- B. Take a shower with perfumed shower gel.
- C. Wear a mask when outside of the home.
- D. Take an antipyretic every morning.
Correct Answer: A
Rationale: Clients with lymphoma may experience pain from lymph node enlargement or treatment. Using analgesics as needed is appropriate for symptom management. Perfumed shower gel may irritate skin, masks are not routinely needed, and daily antipyretics are unnecessary unless fever persists.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible adverse effect of this drug?
- A. Constipation.
- B. Bradycardia.
- C. Diplopia.
- D. Restlessness.
Correct Answer: D
Rationale: Pseudoephedrine is a sympathomimetic that can cause central nervous system stimulation, leading to restlessness. Constipation, bradycardia, and diplopia are not common adverse effects of this medication.
A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy?
- A. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility.'
- B. Potency will be restored, but the client will remain infertile.'
- C. Fertility will be restored, but impotence and decreased libido will persist.'
- D. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.'
Correct Answer: D
Rationale: Hypophysectomy may disrupt pituitary hormone production, including those affecting sexual function. Exogenous hormones (e.g., testosterone) are often needed to restore erectile function.