A nurse is assessing a client who has an obstruction in the small intestine. Clinical manifestations that the nurse would expect include: (SELECT ALL THAT APPLY)

Fecal-smelling breath.

Severe abdominal distention.

Weakness, weight loss, and anorexia.

High-pitched tinkling bowel sounds.

Intense thirst.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Fecal-smelling breath is a symptom of small intestine obstruction due to bacterial fermentation of trapped food, which produces a foul odor that can be detected on the breath.

Choice B rationale

Severe abdominal distention occurs in small intestine obstructions because of the accumulation of gas and fluids proximal to the obstruction site, leading to a noticeable increase in abdominal girth.

Choice C rationale

Weakness, weight loss, and anorexia are more characteristic of chronic gastrointestinal conditions rather than acute small intestine obstruction. These symptoms develop over a longer period and are not acute manifestations.

Choice D rationale

High-pitched tinkling bowel sounds are a typical finding in small intestine obstruction. They occur due to increased peristaltic activity proximal to the obstruction site as the intestines attempt to move the obstructed contents.

Choice E rationale

Intense thirst is not a primary manifestation of small intestine obstruction. While dehydration can occur, it is not specific to small intestine obstruction and can be a result of many other conditions.

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Correct Answer is D

Explanation

Choice A rationale

Lowering a used mask below the chin to reuse it later is not safe as it can lead to contamination of the mask and facial area, increasing the risk of infection.

Choice B rationale

Removing the mask first before any other personal protective equipment (PPE) can lead to contamination and is not the recommended sequence for doffing PPE.

Choice C rationale

Discarding the mask only if it is wet and storing it for reuse is not safe. Masks should not be reused, as they can harbor infectious agents and increase the risk of contamination.

Choice D rationale

Untying the bottom ties first, then the top, and disposing of the mask without touching it ensures that the person removing the mask avoids contamination. This method adheres to proper doffing procedures and minimizes the risk of infection.

A. Request a Foley catheter to be inserted. B. Offer a urinal every 2 hours. C. Encourage fluid intake to keep urine dilute. D. Encourage intake of apple juice to keep urine acidic.

Correct Answer is C

Explanation

Choice A rationale

Requesting a Foley catheter for an older adult patient increases the risk of catheter-associated urinary tract infections (CAUTIs). Avoiding unnecessary catheterization is a better approach to prevent infections.

Choice B rationale

Offering a urinal every 2 hours may not significantly reduce the risk of urinary infections. While it encourages regular voiding, it does not address the need to keep urine dilute to prevent infections.

Choice C rationale

Encouraging fluid intake helps keep urine dilute, which reduces the risk of urinary tract infections. Adequate hydration flushes out bacteria and helps maintain a healthy urinary system.

Choice D rationale

While apple juice can help acidify urine, it is not the primary strategy for preventing urinary infections. Maintaining overall hydration with water is more effective in keeping the urine dilute and reducing infection risk.

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A nurse is assessing a client who has an obstruction in the small intestine. Clinical manifestations that the nurse would expect include: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

When removing a used facemask, the nurse correctly:

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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A nurse is assessing a client who has an obstruction in the small intestine. Clinical manifestations that the nurse would expect include: (SELECT ALL THAT APPLY)