Nokea
Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?
- A. Elevated red blood cell count.
- B. Decreased platelet count.
- C. Elevated white blood cell count.
- D. Elevated serum blood urea nitrogen concentration.
Correct Answer: C
Rationale: Diverticulitis, an inflammatory condition, typically causes an elevated white blood cell count due to infection or inflammation. Red blood cell count, platelet count, and blood urea nitrogen are not directly affected. CN: Physiological adaptation; CL: Analyze
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The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
Which position is best for a client with a hemorrhagic stroke?
- A. Flat supine.
- B. Head elevated 30 degrees.
- C. Prone position.
- D. Trendelenburg position.
Correct Answer: B
Rationale: Head elevation at 30 degrees reduces intracranial pressure while maintaining cerebral perfusion in hemorrhagic stroke.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.
- A. The family is coming in to visit.
- B. The client has increased secretions requiring frequent suctioning.
- C. The SpO2 and PO2 have decreased.
- D. The client is tachycardic with drop in blood pressure.
- E. The face has increased skin breakdown and edema.
Correct Answer: C,D,E
Rationale: Decreased SpO2/PO2 (C), tachycardia with hypotension (D), and facial skin breakdown/edema (E) indicate complications requiring a return to supine position. Family visits and suctioning needs are manageable in prone position.