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Free NCLEX-RN Exam Braindumps (page: 229)

Page 229 of 431
PDF with 862 Questions

A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

  1. It is determined that he has no signs of wound infection
  2. He is able to eat a full meal without evidence of nausea or vomiting
  3. The nurse can detect bowel sounds in all four quadrants
  4. His blood pressure returns to its preoperative baseline level or greater

Answer(s): C

Explanation:

(A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. (D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.



A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when:

  1. It is determined that he has no signs of wound infection
  2. He is able to eat a full meal without evidence of nausea or vomiting
  3. The nurse can detect bowel sounds in all four quadrants
  4. His blood pressure returns to its preoperative baseline level or greater

Answer(s): C

Explanation:

(A) The absence of wound infection is related to his surgical wound and not to postoperative GI functioning and return of peristalsis. (B) Routine postoperative protocol involves detection of bowel sounds and return of peristalsis before introduction of clear liquids, followed by progression of full liquids and a regular diet versus a full regular meal first. (C) Routine postoperative protocol for bowel obstruction is to assess for the return of bowel sounds within 72 hours after major surgery, because that is when bowel sounds normally return. If unable to detect bowel sounds, the surgeon should be notified immediately and have the client remain NPO. (D) Routine postoperative protocol for bowel obstruction and other major surgeries involves frequent monitoring of vital signs in the immediate postoperative period (in recovery room) and then every 4 hours, or more frequently if the client is unstable, on the nursing unit. This includes assessing for signs of hypovolemic shock. Vital signs usually stabilize within the first 24 hours postoperatively.



A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

  1. The behavior is not considered disabling.
  2. More men suffer from agoraphobia than women.
  3. The fears are persistent, and avoidance is used as the coping mechanism.
  4. Agoraphobia moves into remission when treated with chlorpromazine.

Answer(s): C

Explanation:

(A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%­85% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.



A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments. His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?

  1. The behavior is not considered disabling.
  2. More men suffer from agoraphobia than women.
  3. The fears are persistent, and avoidance is used as the coping mechanism.
  4. Agoraphobia moves into remission when treated with chlorpromazine.

Answer(s): C

Explanation:

(A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%­85% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.



Page 229 of 431



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Naveen Ahlam commented on November 29, 2024
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