Extract:

Question 1 of 5

A nurse is assisting with the care of a client who is postoperative following a bowel resection. Which of the following actions should the nurse take?

A. Monitor the client for signs of paralytic ileus.B. Keep the client in a supine position for 24 hr.C. Administer a high-fiber diet immediately.D. Instruct the client to avoid coughing.

Correct Answer: A

Rationale: Paralytic ileus (absent bowel sounds) is a risk post-bowel resection, requiring monitoring. Supine isn't needed, diet starts low-fiber, and coughing is encouraged with support.

Question 2 of 5

A nurse is assisting with the care of a client who is postoperative following a laminectomy. Which of the following actions should the nurse take?

A. Encourage the client to lie flat on their back for 24 hr.B. Monitor the client for urinary retention.C. Instruct the client to perform leg exercises every 4 hr.D. Apply a heating pad to the surgical site.

Correct Answer: B

Rationale: Urinary retention is a risk post-laminectomy due to spinal anesthesia or pain, requiring monitoring. Flat positioning varies, leg exercises are more frequent, and heat isn't standard.

Question 3 of 5

A nurse is reinforcing teaching with a client who has a new prescription for montelukast. Which of the following statements should the nurse include?

A. You should take this medication in the morning.B. You might notice an increase in your asthma symptoms initially.C. This medication might cause you to feel drowsy.D. You should stop taking this medication if your symptoms improve.

Correct Answer: C

Rationale: Montelukast can cause drowsiness, a side effect to note. It's taken at night, improves symptoms over time, and stopping risks recurrence.

Question 4 of 5

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information?

A. Advance directives include instructions for resolving financial matters after my death.B. Federal legislation dictates the legal guidelines for advance directives.C. Advance directives include a living will.D. My medical record should not include my advance directives.

Correct Answer: C

Rationale: Advance directives include a living will, outlining treatment preferences. They don't cover finances, federal law supports but doesn't dictate specifics, and records should include them.

Question 5 of 5

A nurse is assisting with the care of a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

A. Monitor the client's urine output every 8 hr.B. Ensure the irrigation fluid is infused at a rate of 100 mL/hr.C. Check the urine for bright red blood.D. Maintain the irrigation tubing above the level of the bladder.

Correct Answer: C

Rationale: Bright red blood in urine post-TURP signals bleeding, requiring monitoring. Output checks are more frequent, rate varies, and tubing stays below bladder level.