Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when which of the following is noted?
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Solution
Answer B is correct. Lomotil’s desired effect is to decrease GI motility and the number of diarrhea stools. Answers A and D do not occur with the use of Lomotil. The drug should decrease cramping instead of increasing it, as in answer C.
A client with ulcerative colitis requires an illeostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
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Solution
Answer D is correct. Careful cleansing is necessary to prevent skin breakdown and skin irritation. Answer A is not an intervention used for illeostomies. Clients should avoid high fiber and gas-producing foods, as in answer B. Answer C is incorrect because these clients are not on fluid restriction.
A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?
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Solution
Answer D is correct. Questran works by binding the bile acids in the GI tract and eliminating them, decreasing the itching associated with jaundice. Answers A, B, and C are not how Questran works to decrease itching.
The nurse arrives at a four-wheeler accident finding the client nonresponsive, apneic, and pulseless. After calling for a spectator to help, what would be the nurse’s next action?
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Solution
Answer B is correct. The next step after calling for help is to begin chest compressions. Answers A and D are not performed until after answer B, so they are incorrect. Answer C is not a correct procedure because this technique can be utilized only during a witnessed fibrillation.
Assessment findings for the client admitted with a stroke reveal an absence of the gag reflex. The nurse suspects injury to which cranial nerve?
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Solution
Answer B is correct. To test for vagus nerve problems, the nurse uses a tongue blade and depresses the back of the throat to elicit a gag reflex. Other ways to test for damage to the vagus nerve are by having the client say “Ah” while observing for uniform rising of the uvula and the soft palate. The absence of this reflex could indicate damage to the X cranial nerve. Answers A, C, and D are not tested in this manner, so they are incorrect.
Which nursing order would the nurse anticipate for a client with pancreatitis?
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Solution
Answer B is correct. An NG is inserted to decrease the secretion of pancreatic juices and assist in pain relief. Answer A is incorrect because these clients are held NPO. Clients are placed in semi-Fowler’s position, which makes answer C incorrect. Answer D is not appropriate because the wastes are not contaminated.
The nurse is planning shift duties. Which is the least appropriate task for the nursing assistant?
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Solution
Answer D is correct. Assessment is not within the role of a nurse’s assistant, which makes this the least appropriate of the tasks listed. Answers A, B, and C are all appropriate tasks for an assistant, so they are incorrect.
A client who has just undergone a laparoscopic tubal ligation complains of “free air pain.” What would be the nurse’s best action?
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Solution
Answer A is correct. Ambulating the client should help to pass the air. The air is used during the surgical procedure to assist in performance of the surgery. Answers B and C would not help, so they are incorrect. Answer D is not necessary or appropriate at this time.
Which assessment finding in a client with emphysema indicates to the nurse that the respiratory problem is chronic?
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Solution
Answer C is correct. The clinical manifestation of clubbing of the fingers takes time. This indicates that the condition is chronic and not acute, making answer C the correct answer. Answers A, B, and D are all nonspecific for chronicity, so they are incorrect.
A client is being discharged on Coumadin after hospitalization for atrial fibrillation. The nurse recognizes that which of the following foods would be restricted while the client is on this medication?
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Solution
Answer A is correct. Vitamin K would decrease the effects of Coumadin; therefore the client should be taught to restrict green, leafy vegetables, such as broccoli, cabbage, turnip greens, and lettuce. Answers B, C, and D are food choices that are low in vitamin K, so they are incorrect.