Nokea
Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?
- A. Administering pain medication.
- B. Completing the admission history.
- C. Maintaining hydration.
- D. Teaching about planned diagnostic tests.
Correct Answer: A
Rationale: The correct answer is A: Administering pain medication. Immediate pain relief is crucial in managing cholecystitis symptoms and improving the client's comfort. Pain can lead to increased stress, anxiety, and physiological responses that can worsen the condition. Administering pain medication promptly can help alleviate these symptoms and allow the client to rest. Completing the admission history (B) is important but can be done after addressing the urgent pain and discomfort. Maintaining hydration (C) is also essential but may not be the highest priority compared to pain relief. Teaching about planned diagnostic tests (D) is important for the client's understanding but can be deferred until the pain and discomfort are managed effectively.
You may also like to solve these questions
When preparing the client with hepatitis A for extended convalescence, the nurse teaches the client about problems that may occur. The nurse knows that the client has understood the teaching when he says that he is most likely to have difficulty:
- A. Controlling abdominal pain.
- B. Maintaining a regular bowel elimination pattern.
- C. Preventing respiratory complications.
- D. Maintaining a positive, optimistic outlook.
Correct Answer: D
Rationale: The correct answer is D: Maintaining a positive, optimistic outlook. This is because having a positive mindset can help the client cope better with the challenges of extended convalescence. It can improve overall well-being, mental health, and motivation for recovery.
A: Controlling abdominal pain - While abdominal pain may be a symptom of hepatitis A, it is not the most crucial aspect for extended convalescence.
B: Maintaining a regular bowel elimination pattern - While important for overall health, this is not specifically related to complications from hepatitis A.
C: Preventing respiratory complications - While respiratory complications can occur in severe cases of hepatitis A, it is not the most likely difficulty the client will face during extended convalescence.
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?
- A. Leukopenia with a shift to the right
- B. Leukocytosis with a shift to the right
- C. Leukocytosis with a shift to the left
- D. Leukopenia with a shift to the left
Correct Answer: C
Rationale: The correct answer is C: Leukocytosis with a shift to the left. In acute appendicitis, the body responds with an increase in white blood cells (leukocytosis) as a sign of infection. A shift to the left indicates an increase in immature neutrophils, which is a common response to acute bacterial infections like appendicitis. Leukopenia (choices A and D) would not be expected in appendicitis. Leukopenia is a decrease in white blood cells, which is not typical in an acute infection like appendicitis. Leukocytosis with a shift to the right (choice B) could be seen in chronic infections or conditions like leukemia, not in acute appendicitis where a shift to the left is more common due to the rapid response to infection.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?
- A. Increased red blood cell count
- B. Decreased serum ammonia level
- C. Increased protein level
- D. Decreased white blood cell level
Correct Answer: B
Rationale: The correct answer is B: Decreased serum ammonia level. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels through its laxative effect, promoting the excretion of ammonia in the feces. Decreased ammonia levels indicate that the medication is effectively managing the condition. Increased red blood cell count (A), increased protein level (C), and decreased white blood cell level (D) are not directly related to the therapeutic effect of lactulose in hepatic encephalopathy.
The client with a new colostomy is concerned about the odor from stool from the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
- A. Yogurt
- B. Broccoli
- C. Cucumbers
- D. Eggs
Correct Answer: A
Rationale: The correct answer is A: Yogurt. Yogurt contains probiotics that help maintain a healthy balance of gut bacteria, which can reduce the odor of stool in the ostomy drainage bag. Probiotics can also improve digestion and overall gut health. Broccoli (B) and eggs (D) can actually contribute to stronger odors due to their sulfur content. Cucumbers (C) are low in fiber and may not have a significant impact on stool odor.