Nokea
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is specifically used to relieve abdominal distention and flatus by introducing and then removing fluid to stimulate gas expulsion.
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The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. Which recommendation should the nurse include on the poster?
- A. Use a commercial douche on a daily basis.
- B. Perform monthly breast self-examination (BSE).
- C. Seek treatment promptly if cervical infection is suspected.
- D. Use oral contraceptives as a preferred method of birth control.
Correct Answer: C
Rationale: Early treatment of cervical infection can help prevent chronic cervicitis, which can lead to dysplasia of the cervix. Cervical dysplasia is an early cell change that is considered to be premalignant. Douches and oral contraceptives do not decrease the risk for this type of cancer. BSE is useful for early detection of breast cancer, but is unrelated to cervical cancer.
A client with a history of gout is prescribed colchicine. The nurse should instruct the client to take the medication:
- A. Daily to prevent gout attacks.
- B. At the onset of a gout attack.
- C. With meals to enhance absorption.
- D. At bedtime to reduce side effects.
Correct Answer: B
Rationale: Colchicine is most effective when taken at the onset of a gout attack to reduce inflammation and pain.
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
- A. A quiet environment promotes more rapid healing of the aneurysm.
- B. Clients with aneurysms need isolation to cope with photosensitivity.
- C. Reduced environmental stimuli are needed to prevent aneurysm rupture.
- D. The client has disorganization of thoughts and feelings and needs reduced activity.
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?
- A. Obtain a digoxin level to check for toxicity
- B. Note the observation in the chart and plan to reassess in 2 hours
- C. Ask the client if he has been taking aspirin in addition to his other medications
- D. Discontinue the furosemide and notify the physician
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of digoxin toxicity, requiring immediate checking of digoxin levels. Aspirin is less likely to cause this, and discontinuing furosemide or delaying action is inappropriate.
A client has started taking amiodarone (Cordarone). The nurse should inform the client that periodic laboratory tests will be done to monitor the client's:
- A. Hemoglobin.
- B. Liver enzymes.
- C. Creatine kinase (CK) concentration.
- D. Renal function.
Correct Answer: B
Rationale: Amiodarone can cause hepatotoxicity, so periodic monitoring of liver enzymes is necessary to detect potential liver damage.