A patient complains of gas pains and abdominal distention 2 days after a small bowel
resection. Which nursing action should the nurse take?
a. Encourage the patient to ambulate.
b. Instill a mineral oil retention enema.
c. Administer the prescribed IV morphine sulfate.
d. Offer the prescribed promethazine (Phenergan).
Give this one a try later!
, ANS: A
Ambulation will improve peristalsis and help the patient eliminate flatus and
reduce gas pain.
A mineral oil retention enema is helpful for constipation with hard stool. A
return-flow enema
might be used to relieve persistent gas pains. Morphine will further reduce
peristalsis.
Promethazine is used as an antiemetic rather than to decrease gas pains or
distention.
DIF: Cognitive Level: Analyze (analysis) REF: 940
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash
undergoes
peritoneal lavage. If the lavage returns brown fecal drainage, which action will the
nurse plan
to take next?
a. Auscultate the bowel sounds.
b. Prepare the patient for surgery.
c. Check the patient's oral temperature.
d. Obtain information about the accident.
Give this one a try later!
, ANS: B
Return of brown drainage and fecal material suggests perforation of the
bowel and the need
for immediate surgery. Auscultation of bowel sounds, checking the
temperature, and
obtaining information about the accident are appropriate actions, but the
priority is to prepare
to send the patient for emergency surgery.
DIF: Cognitive Level: Analyze (analysis) REF: 941
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
hich nursing diagnosis is of highest priority for a patient with Parkinson's disease who
is unable to move the facial muscles?
a.
Activity intolerance
b.
Self-care deficit: toileting
c.
Ineffective self-health management
d.
Imbalanced nutrition: less than body requirements
Give this one a try later!
ANS: D
The data about the patient indicate that poor nutrition will be a concern
because of decreased swallowing. The other diagnoses may also be
appropriate for a patient with Parkinson's disease, but the data do not
indicate that they are current problems for this patient.
DIF: Cognitive Level: Apply (application) REF: 1436
OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis
MSC: NCLEX: Physiological Integrity
, Which nursing action will be included in the plan of care for a 25-yr-old male patient
with a
new diagnosis of irritable bowel syndrome (IBS)?
a. Encourage the patient to express concerns and ask questions about IBS.
b. Suggest that the patient increase the intake of milk and other dairy products.
c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.
Give this one a try later!
ANS: A
Because psychologic and emotional factors can affect the symptoms for
IBS, encouraging the
patient to discuss emotions and ask questions is an important intervention.
Alosetron has
serious side effects and is used only for female patients who have not
responded to other
therapies. Although yogurt may be beneficial, milk is avoided because
lactose intolerance can
contribute to symptoms in some patients. NSAIDs can be used by patients
with IBS.
DIF: Cognitive Level: Apply (application) REF: 940
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
A patient with diabetes who has bacterial pneumonia is being treated with IV
gentamicin 60
mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating
the
patient's
a. blood glucose.
b. urine osmolality.
c. serum creatinine.
d. serum potassium.
Give this one a try later!
resection. Which nursing action should the nurse take?
a. Encourage the patient to ambulate.
b. Instill a mineral oil retention enema.
c. Administer the prescribed IV morphine sulfate.
d. Offer the prescribed promethazine (Phenergan).
Give this one a try later!
, ANS: A
Ambulation will improve peristalsis and help the patient eliminate flatus and
reduce gas pain.
A mineral oil retention enema is helpful for constipation with hard stool. A
return-flow enema
might be used to relieve persistent gas pains. Morphine will further reduce
peristalsis.
Promethazine is used as an antiemetic rather than to decrease gas pains or
distention.
DIF: Cognitive Level: Analyze (analysis) REF: 940
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash
undergoes
peritoneal lavage. If the lavage returns brown fecal drainage, which action will the
nurse plan
to take next?
a. Auscultate the bowel sounds.
b. Prepare the patient for surgery.
c. Check the patient's oral temperature.
d. Obtain information about the accident.
Give this one a try later!
, ANS: B
Return of brown drainage and fecal material suggests perforation of the
bowel and the need
for immediate surgery. Auscultation of bowel sounds, checking the
temperature, and
obtaining information about the accident are appropriate actions, but the
priority is to prepare
to send the patient for emergency surgery.
DIF: Cognitive Level: Analyze (analysis) REF: 941
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
hich nursing diagnosis is of highest priority for a patient with Parkinson's disease who
is unable to move the facial muscles?
a.
Activity intolerance
b.
Self-care deficit: toileting
c.
Ineffective self-health management
d.
Imbalanced nutrition: less than body requirements
Give this one a try later!
ANS: D
The data about the patient indicate that poor nutrition will be a concern
because of decreased swallowing. The other diagnoses may also be
appropriate for a patient with Parkinson's disease, but the data do not
indicate that they are current problems for this patient.
DIF: Cognitive Level: Apply (application) REF: 1436
OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis
MSC: NCLEX: Physiological Integrity
, Which nursing action will be included in the plan of care for a 25-yr-old male patient
with a
new diagnosis of irritable bowel syndrome (IBS)?
a. Encourage the patient to express concerns and ask questions about IBS.
b. Suggest that the patient increase the intake of milk and other dairy products.
c. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).
d. Teach the patient about the use of alosetron (Lotronex) to reduce IBS symptoms.
Give this one a try later!
ANS: A
Because psychologic and emotional factors can affect the symptoms for
IBS, encouraging the
patient to discuss emotions and ask questions is an important intervention.
Alosetron has
serious side effects and is used only for female patients who have not
responded to other
therapies. Although yogurt may be beneficial, milk is avoided because
lactose intolerance can
contribute to symptoms in some patients. NSAIDs can be used by patients
with IBS.
DIF: Cognitive Level: Apply (application) REF: 940
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
A patient with diabetes who has bacterial pneumonia is being treated with IV
gentamicin 60
mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating
the
patient's
a. blood glucose.
b. urine osmolality.
c. serum creatinine.
d. serum potassium.
Give this one a try later!
