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 used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.
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The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
- A. Bring the child to the emergency department immediately.
- B. It is not an emergency, but it is best to call the health care clinic.
- C. It is important to replace them immediately so that the surgical opening does not close.
- D. Clean the tubes with half-strength hydrogen peroxide for 30 minutes and then replace them into the child's ears.
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
You are caring for a client who has just had a thoracentesis. Which complication should you be aware of during the immediate post-operative period of time?
- A. Infection
- B. Pneumothorax
- C. Aspiration
- D. Dyspnea
Correct Answer: B
Rationale: Pneumothorax is a potential complication of thoracentesis due to the risk of lung puncture during the procedure, requiring immediate monitoring.
The nurse should instruct the client prescribed docusate to monitor for which intended effect of the medication?
- A. Abdominal pain
- B. Decreased heartburn
- C. Decrease in fatty stools
- D. Regular bowel movements
Correct Answer: D
Rationale: Docusate is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not relieve abdominal pain, relieve heartburn, or decrease the amount of fat in the stools.
The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
- A. Do you often need help with food shopping?
- B. Let's discuss how we can solve this problem.
- C. Do you have any support systems for shopping?
- D. I wish I could but I don't have time to run errands.
Correct Answer: B
Rationale: The nurse's duty is to help the client; but in helping the client, the nurse's first action is to finish the assessment and then find immediate and long-term solutions to the problem. In options 1 and 3 the nurse asks a closed-ended question, which is unlikely to further nurse-client communication. Option 4 is inappropriate while failing to address the client's problem.
After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.