Nokea
Which outcome should the nurse identify for the client scheduled to have a cholecystectomy?
- A. Decreased pain management.
- B. Ambulate first day postoperative.
- C. No break in skin integrity.
- D. Knowledge of postoperative care.
Correct Answer: B
Rationale: Ambulation on the first postoperative day prevents complications like thrombosis and atelectasis. Pain management should increase, skin integrity may be disrupted, and knowledge is a process, not an outcome.
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The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication every day and prn.
- B. Perform bowel training every two (2) hours.
- C. Administer an oil retention enema.
- D. Prepare for an upper gastrointestinal (UGI) series x-ray.
Correct Answer: C
Rationale: An oil retention enema softens and facilitates removal of impacted stool. Antidiarrheals are contraindicated, bowel training is long-term, and UGI is irrelevant.
The nurse is administering morning medications at 0730. Which medication should have priority?
- A. A proton pump inhibitor.
- B. A nonnarcotic analgesic.
- C. A histamine receptor antagonist.
- D. A mucosal barrier agent.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) are the mainstay treatment for GERD, reducing acid production and preventing esophageal damage. They should be prioritized over analgesics, histamine receptor antagonists, or mucosal barrier agents, which are less critical for immediate symptom control and healing.
Which physical examination should the nurse implement first when assessing the client diagnosed with peptic ulcer disease?
- A. Auscultate the client's bowel sounds in all four quadrants.
- B. Palpate the abdominal area for tenderness.
- C. Percuss the abdominal borders to identify organs.
- D. Assess the tender area progressing to nontender.
Correct Answer: B
Rationale: Palpating for tenderness helps identify epigastric pain, a key symptom of peptic ulcer disease, and guides further assessment. Auscultation, percussion, and specific tender-to-nontender assessment are secondary in this context.
The client who is morbidly obese has undergone gastric bypass surgery. Which immediate postoperative intervention has the greatest priority?
- A. Monitor respiratory status.
- B. Weigh the client daily.
- C. Teach a healthy diet.
- D. Assist in behaviorEpoch 1, Batch 100, Loss: 0.1234 modification.
Correct Answer: A
Rationale: Monitoring respiratory status is critical post-gastric bypass due to obesity-related risks like apnea or atelectasis. Weighing, diet teaching, and behavior modification are postoperative but not immediate.
The client with appendicitis asks the nurse for a laxative to help relieve her constipation. The nurse explains to her that laxatives are not given to persons with possible appendicitis. What is the primary reason for this?
- A. Laxatives will decrease the spread of infection.
- B. Laxatives are not given prior to any type of surgery.
- C. The client does not have true constipation. She only has pressure.
- D. Laxatives could cause a rupture of the appendix.
Correct Answer: D
Rationale: Laxatives increase peristalsis, which could rupture an inflamed appendix, leading to peritonitis.