Nokea
Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
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The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has:
- A. Mild peripheral artery disease
- B. Moderate peripheral artery disease
- C. No apparent occlusion in the left lower extremity
- D. Severe peripheral artery disease
Correct Answer: A
Rationale: ABI = ankle systolic BP ÷ arm systolic BP = 130 ÷ 160 = 0.81. An ABI of 0.8–0.9 indicates mild peripheral artery disease, suggesting some arterial narrowing. Normal ABI is 0.9–1.3, moderate is 0.5–0.8, and severe is <0.5.
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.
One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. Which of the following indicates that the client has attained the goal? The client has:
- A. Regained weight loss.
- B. Resumed normal dietary intake of three meals a day.
- C. Controlled nausea and vomiting through regular use of antiemetics.
- D. Achieved optimal nutritional status through oral or parenteral feedings.
Correct Answer: D
Rationale: Achieving optimal nutritional status, whether through oral or parenteral feedings, is the primary goal one month post-gastrectomy, as it indicates the client is meeting nutritional needs.
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
- A. Supplement the diet with daily multivitamins.
- B. Limit daily alcohol intake.
- C. Take a sleeping pill at bedtime.
- D. Limit contact with other people whenever possible.
Correct Answer: A
Rationale: Multivitamins (A) support nutrition in cirrhosis. Alcohol (B) must be avoided entirely. Sleeping pills (C) risk encephalopathy. Social isolation (D) is unnecessary.