Question

A nurse is planning care for a client who is 1 day postoperative following a partial bowel resection. The client requires a complete dressing change, total parenteral nutrition administration, daily weight and is reporting pain at a level of 6 on a 0 to 10 scale. Which of the following nursing actions should the nurse plan to complete first?

Answer 1

Correct Answers:

Administer pain medication.

Rationale :

🟣 According to Maslow's hierarchy, pain relief is a physiological need and takes priority.

🟣 Addressing the pain first promotes comfort and cooperation with other interventions like dressing changes.

🟣 Unrelieved pain can lead to stress responses that impair healing.

🟣 Administering pain meds ensures the client can tolerate subsequent necessary activities like weighing and dressing care.

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Answer 2

Correct Answers:

“Monitor blood glucose levels every 4 hours.”

Rationale :

🔵 During illness, clients with type 1 diabetes are at high risk for DKA or hypoglycemia.

🔵 Frequent glucose monitoring enables timely intervention and adjustment of insulin and intake.

🔵 This action is essential for detecting fluctuations and preventing life-threatening complications.

🔵 Sick-day management begins with vigilant self-monitoring.

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Answer 3

Correct Answers:

Drinking orange juice regularly

Rationale :

🟡 Orange juice is highly acidic and can contribute significantly to esophageal irritation in clients with gastroesophageal reflux disease (GERD).

🟡 Acidic beverages such as citrus juices (e.g., orange, grapefruit, and lemon juice) lower the pH of stomach contents, and when refluxed, can worsen inflammation of the esophageal mucosa.

🟡 Additionally, these acids can cause relaxation of the lower esophageal sphincter (LES), the muscular ring that prevents backflow of stomach contents into the esophagus.

🟡 LES relaxation increases the likelihood of gastric contents refluxing, leading to heartburn, especially when consumed in the evening or close to bedtime.

🟡 Clients with GERD should be taught to avoid common dietary triggers including citrus, caffeine, chocolate, fatty foods, and carbonated beverages.

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Answer 4

Correct Answers:

Determine the client’s calcium level.

Rationale :

🔴 Post-thyroidectomy clients are at risk for hypocalcemia due to potential damage to the parathyroid glands.

🔴 Symptoms include muscle spasms, tingling, tetany, and potentially seizures.

🔴 Prompt identification and treatment of low calcium is life-saving.

🔴 Serum calcium monitoring is a critical post-op assessment.

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Answer 5

Correct Answers:

Docusate

Rationale :

🟢 Corticosteroids reduce inflammation during acute exacerbations of ulcerative colitis.

🟢 They help relieve abdominal pain, bleeding, and diarrhea.

🟢 Other options like cathartics and NSAIDs may worsen symptoms or cause mucosal damage.

🟢 Anti-inflammatory treatment is the cornerstone of acute management.

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Answer 6

Correct Answers:

Check for bleeding on the dressing at the back of the client’s neck.

Rationale :

⚪ Post-thyroidectomy bleeding can pool behind the neck, risking airway compression.

⚪ Early detection of hematoma prevents respiratory distress.

⚪ Monitoring the posterior dressing is essential in the first hours post-op.

⚪ Semi-Fowler's positioning also helps reduce swelling and improve breathing.

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Answer 7

Correct Answers:

“You may feel some cramping during the procedure.”

Rationale :

🟠 Colonoscopy may cause cramping or pressure as the scope advances through the colon.

🟠 The client receives sedation, but sensations may still be present.

🟠 Honest information reduces anxiety and builds trust with the nurse.

🟠 The nurse should avoid overpromising comfort or memory loss.

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Answer 8

Correct Answers:

Spider angioma

Rationale :

🟣 Spider angiomas are vascular lesions associated with elevated estrogen in liver failure.

🟣 Cirrhosis impairs the liver’s ability to metabolize hormones, causing visible changes.

🟣 These lesions commonly appear on the face, chest, and arms.

🟣 Other signs include jaundice, ascites, and gynecomastia.

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Answer 9

Correct Answers:

Disinfect equipment with bleach solution

Rationale :

🟤 C. difficile spores are resistant to alcohol and most cleaners but can be killed by bleach.

🟤 Proper disinfection is critical to prevent spread in healthcare settings.

🟤 Handwashing with soap and water is required instead of sanitizer.

🟤 Contact precautions and bleach cleaning are standard protocol.

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Answer 10

Correct Answers:

Faty stools

Rationale :

🟢 Obstruction of the common bile duct prevents bile from emulsifying fats, leading to steatorrhea (fatty stools).

🟢 Stools may appear pale, bulky, and foul-smelling.

🟢 Cholelithiasis with duct blockage also causes RUQ pain and jaundice.

🟢 Bile is essential for fat digestion and absorption.

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QLexNursing

2 :
A nurse is reinforcing teaching with a client who has diabetes mellitus type 1 about sick-day management. Which of the following is the priority action for the nurse to recommend to the client?

3 :
A nurse is collecting data from a client who has gastroesophageal reﬂux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client’s heartburn?

4 :
A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

5 :
A nurse is reviewing the plan of care for a client experiencing an acute exacerbation of ulcerative colitis. Which of the following treatments should the nurse expect to administer?

6 :
A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

7 :
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

8 :
A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

9 :
A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

10 :
A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

QLexNursing

2 : A nurse is reinforcing teaching with a client who has diabetes mellitus type 1 about sick-day management. Which of the following is the priority action for the nurse to recommend to the client?

3 : A nurse is collecting data from a client who has gastroesophageal reﬂux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client’s heartburn?

4 : A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

5 : A nurse is reviewing the plan of care for a client experiencing an acute exacerbation of ulcerative colitis. Which of the following treatments should the nurse expect to administer?

6 : A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

7 : A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

8 : A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

9 : A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

10 : A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

2 :
A nurse is reinforcing teaching with a client who has diabetes mellitus type 1 about sick-day management. Which of the following is the priority action for the nurse to recommend to the client?

3 :
A nurse is collecting data from a client who has gastroesophageal reﬂux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client’s heartburn?

4 :
A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

5 :
A nurse is reviewing the plan of care for a client experiencing an acute exacerbation of ulcerative colitis. Which of the following treatments should the nurse expect to administer?

6 :
A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?

7 :
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

8 :
A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

9 :
A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

10 :
A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?