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Which task should the nurse delegate to the unlicensed assistive personnel (UAP) to improve the desire to eat in a 14-year-old client diagnosed with anorexia?
- A. Administer an antiemetic 30 minutes before the meal.
- B. Provide mouth care with lemon-glycerin swabs prior to the meal.
- C. Create a social atmosphere by interacting with the client.
- D. Encourage the client's parents to sit with the client during meals.
Correct Answer: D
Rationale: Encouraging parents to sit with the client is within the UAP’s scope and promotes a supportive eating environment. Administering medication, mouth care, and creating a social atmosphere require RN skills or specific training.
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Which intervention should the nurse include when discussing ways to help prevent potential episodes of gastroenteritis from Clostridium botulism?
- A. Make sure all hamburger meat is well cooked.
- B. Ensure all dairy products are refrigerated.
- C. Discuss why campers should drink only bottled water.
- D. Discard damaged canned goods.
Correct Answer: D
Rationale: Clostridium botulinum thrives in improperly canned foods, so discarding damaged cans prevents botulism. Cooking meat, refrigerating dairy, and bottled water are unrelated to botulism.
The client is two (2) hours post colonoscopy. Which assessment data warrant immediate intervention by the nurse?
- A. The client has a soft, nontender abdomen.
- B. The client has a loose, watery stool.
- C. The client has hyperactive bowel sounds.
- D. The client's pulse is 104 and BP is 98/60.
Correct Answer: D
Rationale: Tachycardia (pulse 104) and low BP (98/60) suggest possible bleeding or hypovolemia post-colonoscopy, requiring immediate intervention. A soft abdomen, watery stool, and hyperactive bowel sounds are expected.
During a home visit, the client’s spouse reports that since her husband’s placement of a colostomy 3 months ago, he has lost interest in golf. She also says he cries often for no reason, sleeps for only a few hours at night, and reports fatigue. The wife asks the nurse for advice. Which statement should be the basis for the nurse’s response?
- A. One in four clients develops depression after ostomy surgery.
- B. Athletic activities like golf are not possible after ostomy surgery.
- C. After 3 months the client should have accepted his new body image.
- D. The smell and location make it difficult to sleep well with an ostomy.
Correct Answer: A
Rationale: The client is exhibiting signs of depression. At least 25% of clients develop clinically significant depression following colostomy. Poor adjustment to a stoma correlates to development of depression.
The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?
- A. Monitor the blood glucose levels
- B. Administer enteral feedings
- C. Irrigate the NG tube with 30 mL of saline
- D. Assist with bowel elimination within 8 hours of surgery
Correct Answer: A
Rationale: A. The Whipple procedure induces insulin-dependent diabetes because the proximal pancreas is resected. Thus, the blood glucose levels should be monitored closely starting immediately after surgery. B. Parenteral (not enteral) feedings are the method of choice for providing nutrition immediately after surgery. C. The NG tube is strategically placed during surgery and should not be irrigated without a surgeon’s order. With an order, gentle irrigation with 10 to 20 mL of NS is appropriate. D. Since this surgery reshapes the GI tract, the client will not have peristalsis and bowel movements for several days.
The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?
- A. The nursing care plan for postoperative day one indicates restricting fluids to 30—60 mL per hour of clear liquids.
- B. The nurse is instructing the licensed practical nurse (LPN) to remove the client’s urinary catheter 24 hours after surgery.
- C. The client is wearing a bilevel positive airway pressure (BiPAP) mask when sleeping during the day.
- D. A bottle of saline and 60-mL catheter-tip syringe are on the bedside table for nasogastric (NG) tube irrigation.
Correct Answer: D
Rationale: A. For the first 24-48 hours postoperatively, the client sips small amounts of clear liquids to avoid nausea, vomiting, and distention and stress on the suture line. B. If used, urinary catheters should be removed within 24 hours after surgery to prevent UTIs and to encourage mobility. The nurse may delegate this task to an LPN. C. The BiPAP mask is used to keep the airway open and should be worn whenever the client is sleeping. D. A bottle of saline and a large-sized syringe may indicate that the client’s NG tube has been or will be irrigated. Manipulating or irrigating an NG tube with too much solution can lead to disruption of the anastomosis in gastric surgeries. If an NG tube is present the surgeon should be consulted before irrigating the tube.