the client has been diagnosed with hemorrhoids which statement from the client indicates that further teaching is needed

ATI RN

ATI RN Custom Exams Set 5

1. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?

A. “I should increase fruits, bran, and fluids in my diet.”
B. “I will use warm compresses and take sitz baths daily.”
C. “I must take a laxative every night and have a stool daily.”
D. “I can use an analgesic ointment or suppository for pain.”

Correct answer: C

Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.

2. What causes hepatic encephalopathy?

A. Buildup of ammonia in the body
B. Buildup of urea in the body
C. Fatty infiltration of the liver
D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

3. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

A. Assist the client in ambulating
B. Assess the client's bilateral pedal pulses
C. Maintain a continuous IV heparin drip
D. Provide clear liquids to the client

Correct answer: B

Rationale: Assessing the client's bilateral pedal pulses is essential in this situation as it helps in evaluating the peripheral perfusion and circulation in the lower extremities. This assessment is crucial to detect any signs of decreased blood flow or complications, such as arterial occlusion or thrombosis. Ambulating the client may be important in the postoperative period, but assessing pedal pulses takes priority to ensure adequate perfusion. Maintaining continuous IV heparin drip is not typically indicated immediately post-operatively for an abdominal aortic aneurysm repair, as the risk of bleeding complications may outweigh the benefits. Providing a clear liquid diet is not a priority nursing intervention at this stage, as the focus should be on vascular assessment and postoperative monitoring.

4. Which laboratory data indicate the client’s pancreatitis is improving?

A. The amylase and lipase serum levels are decreased
B. The white blood cell count (WBC) is decreased
C. The conjugated and unconjugated bilirubin levels are decreased
D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.

5. Which intervention should the nurse implement for the client who has an ileal conduit?

A. Pouch the stoma with a one-inch margin around the stoma
B. Refer the client to the United Ostomy Association for discharge teaching
C. Report to the healthcare provider any decrease in urinary output
D. Monitor the stoma for signs and symptoms of infection every shift

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.