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1. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will drink liquids right up until the procedure.
- B. I will need to stop eating and drinking at least 24 hours before the procedure.
- C. I will be sedated and will not feel any pain during the procedure.
- D. I will not need to follow any specific dietary restrictions for this procedure.
Correct answer: C
Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.
2. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?
- A. Hyperactive reflexes.
- B. Strong, bounding pulse.
- C. Decreased bowel sounds.
- D. Increased deep tendon reflexes.
Correct answer: C
Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.
3. A healthcare provider is collecting data from a client who has multiple sclerosis. Which of the following findings should the healthcare provider expect?
- A. Fever
- B. Ataxia
- C. Nystagmus
- D. Fatigue
Correct answer: B
Rationale: Ataxia, which refers to difficulty with coordination, is a common symptom seen in individuals with multiple sclerosis. Nystagmus, the involuntary eye movement, can also occur in multiple sclerosis but is not as common as ataxia. Fatigue is a common symptom in multiple sclerosis, but ataxia is more specific. Fever is not a typical finding associated with multiple sclerosis.
4. A nurse is caring for a client who is experiencing chronic pain. Which of the following interventions should the nurse implement?
- A. Provide the client with distractions such as television
- B. Administer pain medication around the clock
- C. Teach the client relaxation techniques
- D. Perform massage therapy on the client
Correct answer: C
Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques, as it helps in managing pain more effectively by reducing stress and anxiety. Distractions like television (Choice A) may offer temporary relief but do not address the root cause of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote long-term pain management. While massage therapy (Choice D) can be beneficial, teaching relaxation techniques (Choice C) is more directly focused on empowering the client to manage their pain independently.
5. A client has an NG tube that needs irrigation every 8 hours. Which solution should be used to irrigate the tube to maintain fluid and electrolyte balance?
- A. Tap water
- B. Sterile water
- C. 0.9% sodium chloride
- D. 0.45% sodium chloride
Correct answer: C
Rationale: The correct answer is 0.9% sodium chloride. This solution is isotonic and helps maintain electrolyte balance during irrigation, preventing fluid and electrolyte imbalances. Tap water (choice A) may cause electrolyte imbalances due to its hypotonic nature. Sterile water (choice B) is hypotonic and can lead to electrolyte disturbances. 0.45% sodium chloride (choice D) is hypotonic and may also disrupt electrolyte balance when used for irrigation.
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