Nokea
Which signs and symptoms should the nurse report to the health-care provider for the client recovering from an open cholecystectomy?
- A. Clay-colored stools.
- B. Yellow-tinted sclera.
- C. Amber-colored urine.
- D. WGold-colored urine.
- E. Wound approximated.
- F. Abdominal pain.
Correct Answer: A,B,E
Rationale: Clay-colored stools and yellow-tinted sclera indicate possible bile duct obstruction or jaundice, while abdominal pain suggests complications like infection or bile leak, all requiring HCP notification. Amber urine and approximated wounds are less urgent.
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Which complaint is significant for the nurse to assess in the adolescent male client who uses oral tobacco?
- A. The client complains of clear to white sputum.
- B. The client has an episodic blister on the upper lip.
- C. The client complains of a nonhealing sore in the mouth.
- D. The client has bilateral ducts at the second molars.
Correct Answer: C
Rationale: A nonhealing sore in the mouth is concerning for oral cancer, a risk associated with oral tobacco use, requiring immediate assessment. Sputum, blisters, and salivary ducts are less significant.
The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid.
- B. Encourage the client to ventilate feelings about body image.
- C. Administer opioid narcotic medications for pain management.
- D. Assist the client out of bed to sit in the chair twice daily.
Correct Answer: B
Rationale: Encouraging ventilation of feelings about body image is an independent nursing intervention addressing psychosocial needs post-colostomy. IV rate, opioids, and ambulation require orders or are less psychosocial.
The client is diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
- A. Instruct the client to avoid drinking fluids with meals.
- B. Explain the need to decrease intake of flatus-forming foods.
- C. Teach the client how to perform gentle perianal care.
- D. Encourage the client to attend a support group meeting.
Correct Answer: B
Rationale: Decreasing flatus-forming foods (e.g., beans, broccoli) reduces bloating and discomfort in IBS. Avoiding fluids with meals is not standard, perianal care is secondary, and support groups are psychosocial.
Which intervention should the nurse implement when administering a potassium supplement?
- A. Determine the client's allergies.
- B. Ask the client about leg cramps.
- C. Monitor the client's blood pressure.
- D. Monitor the client's complete blood count.
Correct Answer: B
Rationale: Asking about leg cramps assesses for hypokalemia symptoms, ensuring the potassium supplement is needed and effective. Allergies, BP, and CBC are less specific.
The client is diagnosed with an acute exacerbation of inflammatory bowel disease (IBD). Which food selection would be the best choice for a meal?
- A. Roast beef on wheat bread and a milk shake.
- B. Hamburger, french fries, and a cola.
- C. Pepper steak, brown rice, and iced tea.
- D. Roasted turkey, instant mashed potatoes, and water.
Correct Answer: D
Rationale: Roasted turkey, instant mashed potatoes, and water are low-residue, easy-to-digest foods suitable for acute IBD exacerbation. Other options are high-fiber or irritating.