Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?
A. Encouraging the client to increase intake of foods that contain high fat to increase GI motility.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
B. Encouraging the client to increase solid food intake to promote peristalsis.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
C. Encouraging the client to increase intake of foods that contain fiber.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
D. Withholding food and oral fluids until intestinal mobility has returned.
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
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Full Explanation
Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.
Giving food and fluids to a client with POI may worsen the condition and cause complications.
Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.
Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.
Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.
Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.
Similar Questions
The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD).
Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?
A. An influenza vaccine.
This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.
B. A broad-spectrum antibiotic.
A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.
C. A bronchodilator.
A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.
D. A corticosteroid.
A costeroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.
Full Explanation
This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.
Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.
Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.
Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.
A nurse is caring for a client whose family is in a state of disagreement over the care of their family member.
The nurse should report the situation to which of the following facility personnel?
A. Clinical education specialist.
Choice A is wrong because a clinical education specialist is not directly involved in the client’s care and does not have the authority to intervene in ethical issues.
B. Quality improvement committee.
Choice B is wrong because a quality improvement committee is responsible for monitoring and evaluating the quality of care and services provided by the facility, not for addressing ethical conflicts.
C. Hospital ethics committee.
The nurse should report the situation to the hospital ethics committee, which is used to resolve ethical dilemmas in the health care setting. The hospital ethics committee can help the nurse and the client’s family reach a consensus on the best course of action for the client.
D. Hospital administrator.
Choice D is wrong because a hospital administrator is not usually involved in the clinical decision-making process and may not have the expertise or time to deal with ethical issues.
Full Explanation
The nurse should report the situation to the hospital ethics committee, which is used to resolve ethical dilemmas in the health care setting. The hospital ethics committee can help the nurse and the client’s family reach a consensus on the best course of action for the client.
Choice A is wrong because a clinical education specialist is not directly involved in the client’s care and does not have the authority to intervene in ethical issues.
Choice B is wrong because a quality improvement committee is responsible for monitoring and evaluating the quality of care and services provided by the facility, not for addressing ethical conflicts.
Choice D is wrong because a hospital administrator is not usually involved in the clinical decision-making process and may not have the expertise or time to deal with ethical issues.
Signs of hemolytic anaemias include:
A. Red, sore tongue.
Choice A is wrong because a red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anaemia.
B. Pica.
Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia.
C. Splenomegaly and Jaundice.
Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made. Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown.
D. Paresthesias.
Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia. Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.
Full Explanation
Splenomegaly and jaundice are signs of hemolytic anemia, a disorder in which red blood cells are destroyed faster than they are made.
Splenomegaly is an enlargement of the spleen, which may trap and destroy healthy red blood cells. Jaundice is a yellowing of the skin and eyes caused by the buildup of bilirubin, a waste product of hemoglobin breakdown. Choice A is wrong because red, sore tongue is a sign of vitamin B12 deficiency anemia, not hemolytic anemia.
Choice B is wrong because pica is a craving for nonfood items, such as ice, dirt, or starch. It is a sign of iron deficiency anemia, not hemolytic anemia. Choice D is wrong because paresthesias are sensations of tingling, numbness, or prickling in the hands or feet. They are a sign of pernicious anemia, a type of vitamin B12 deficiency anemia, not hemolytic anemia.
Normal ranges for red blood cell count are 4.5 to 5.9 million cells per microliter for men and 4.1 to 5.1 million cells per microliter for women. Normal ranges for hemoglobin are 13.5 to 17.5 grams per deciliter for men and 12.0 to 15.5 grams per deciliter for women. Normal ranges for bilirubin are 0.1 to 1.2 milligrams per deciliter for adults.