Nokea
Which of the following should be a priority focus of care for a client experiencing an exacerbation of Crohn's disease?
- A. Encouraging regular ambulation.
- B. Promoting bowel rest.
- C. Maintaining current weight.
- D. Decreasing episodes of rectal bleeding.
Correct Answer: B
Rationale: Promoting bowel rest is the priority during a Crohn's exacerbation to reduce inflammation and symptoms. Ambulation, weight maintenance, and reducing bleeding are secondary to resting the bowel. CN: Physiological adaptation; CL: Synthesize
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The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?
- A. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.
- B. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.
- C. Explain to the client that she will have a premedication that will make her sleep before she goes to surgery and she won't need to hear.
- D. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.
Correct Answer: D
Rationale: Calling the surgery unit to discuss the client's need for a hearing aid ensures her communication needs are addressed while adhering to surgical safety protocols. This action balances patient advocacy with policy considerations.
Cortisone acetate (Cortone) and fludrocortisone acetate (Florinef Acetate) are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy?
- A. Take both drugs three times a day.
- B. Take the entire dose of both drugs first thing in the morning.
- C. Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon.
- D. Take half of each drug in the morning and the remaining half of each drug at bedtime.
Correct Answer: C
Rationale: Mimicking diurnal cortisol patterns, most cortisone and all fludrocortisone are taken in the morning, with the remaining cortisone in the afternoon.
The nurse should remind family members who are visiting a client with granulocytopenia to:
- A. Visit only if they do not have a cold.
- B. Wash their hands.
- C. Leave the children at home.
- D. Avoid kissing the client on the lips.
Correct Answer: B
Rationale: Hand washing is the most effective way to prevent transmission of pathogens to a granulocytopenic client, who is at high risk for infection. While avoiding colds, leaving children at home, and avoiding kissing are helpful, hand washing is the priority.
The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include:
- A. Minimizing dyspnea.
- B. Maintaining adequate blood pressure control.
- C. Decreasing myocardial contractility.
- D. Preventing fluid volume deficit.
Correct Answer: B
Rationale: Maintaining adequate blood pressure post-PTCA ensures coronary perfusion and prevents complications like stent thrombosis or ischemia.
A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
- A. Deficient fluid volume.
- B. Intestinal obstruction.
- C. Bowel ischemia.
- D. Peritonitis.
Correct Answer: D
Rationale: Fever, tachycardia, and hypotension in acute appendicitis suggest peritonitis, a complication from possible appendiceal rupture. Deficient fluid volume, obstruction, or ischemia are less directly indicated by these signs. CN: Physiological adaptation; CL: Analyze