Module 7 Exam

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen?

Spinach salad, milk, and a banana

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about lower back care. The nurse determines that the client needs further instruction if the client makes which statement?

"I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

A home care nurse makes a visit to a new mother who delivered a 7-lb girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by telling the mother which information?

"Most newborns sleep about 16 hours a day."

A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the clientis receiving this medication?

Tachycardia Hypotension Mental clouding Side/adverse effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.

The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items?

Coffee Cola Chocolate Theophylline is a methylxanthine bronchodilator, and the nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, tea, cola, and chocolate.

Which food should the nurse offer to a client who has been prescribed a full liquid diet?

Cooked custard A full liquid diet consists of liquid foods that are clear or opaque liquid foods, including those that are liquid at room temperature. Cooked custard is allowed on a full liquid diet. Toast and a bagel are allowed on a regular diet (a diet with no restrictions). Scrambled eggs are allowed on a soft diet.

An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which action?

Giving the client a complete bed bath A complete bed bath is for clients who are totally dependent and require total hygiene care. The nurse would promote independence and encourage the client to assist as much as possible in the bath. The nurse would maintain the room's warmth because the client is partially uncovered and may easily be chilled. Privacy is always maintained, and the nurse maintains safety by keeping the side rails up (per agency policy) while away from the client's bedside.

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet?

Meat and citrus fruit The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron is absorbed from eggs and less than 5% from grains and vegetables.

A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection?

The ureterovesical junction The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter, in essence acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys.

A nurse is preparing to administer an enema to a client. In which position does the nurse place the client?

c

The nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction?

eggs One large egg provides 66 mg of potassium. A half-cup (114 gm) of raisins contains 700 mg of potassium. Four ounces (113 gm) of beef contains 420 mg of potassium, and 4 oz of pork (113 gm) contains 525 mg. eggs lowest in K

A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse explains that a cold pack has which action?

Reduces blood flow to the extremity

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches?

4 inches The nurse inserts the rectal tube slowly, pointing the tip of the tube in the direction of the client's umbilicus. In an adult client the tube is inserted 3 to 4 inches (7.5 to 10 cm), in a child 2 to 3 inches (5 to 7.5 cm), and in an infant 1 to 1½ inches (2.5 to 3.8 cm).

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position?

8 inches (20 cm) to the front and side of the toes The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed between 6 and 10 inches (15 to 25.5 cm) in front and to the side of the client, depending on the client's body size, providing a wide enough base of support and improving the client's balance.

. A nurse is following a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should the nurse expect to be included in the plan of care to help maintain an appropriate bowel elimination pattern?

Providing cooked fruits such as prunes or apricots

A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?

Right Heel Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg, which is used as a brace when the client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. The nurse should provide which instruction?

This is a normal occurrence as a person gets older.

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectiveness of the tube feedings?

Daily weight

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods?

Peanuts Asparagus Whole grain cereals Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin, but other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals. Milk is high in vitamins A and D, calcium, and magnesium. Chicken is high in protein. Broccoli is high in calcium and folic acid.

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine sample. What should the nurse tell the client?

That she should cleanse the perineum from front to back

A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement?

"I can pin the pad around the affected area." One conventional form of heat therapy is the electric heating pad. The nurse instructs the client to avoid using the pad on the high setting and to never lie on the pad, because these actions can result in burns. The client is also instructed not to insert a safety pin through the pad, which could result in an electric shock. The client must check the skin frequently for redness.

A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered?

1000 ml

A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day?

2000-2500

A nurse asks the unlicensed assistive personnel to provide afternoon care to a client. The nurse expects that the unlicensed assistive personnel will take which action?

Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

The nurse is assigned to care for four clients. Which client does the nurse recognize is likely to experience chronic pain?

A client with osteoarthritis

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet?

Alcohol A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the client not to drink alcohol while taking this medication.

A nurse is following a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse expect to see included in the plan of care?

Asking the client what she does to prepare for sleep

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action?

Aspirating the fluid, advancing the catheter farther, and reinflating the balloon If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, resulting in pain. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space in which to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter or call the HCP. Because pain on balloon inflation is not normal, having the client take deep breaths is not an appropriate action.

A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery. The nurse responds by telling the client that in this technique, the client will experience which response?

Becomes less aware of pain by creating and then concentrating on a mental image

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food that just arrived on the client's meal tray should the nurse discourage the client from eating?

Bran

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu?

Chicken breast, broccoli, strawberries, milk Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice, and bread deliver complex carbohydrates. Spare ribs may contain some protein but are high in fat.

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications?

Drinking liquids with meals

A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process?

Glomerular filtration rate (GFR) is diminished As part of the normal aging process, the GFR decreases, like all of the other functional capabilities of the kidney. The kidneys' capacity to metabolize medications diminishes. Tubular reabsorption and urine-concentrating capacity also decrease.

The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene?

Having the client assist by using the overhead trapeze In the safe care of a client after lumbar spinal fusion, the head of the bed is generally kept flat. The client is log-rolled from side to side as prescribed. As a matter of surgeon preference, pillows may be placed under the entire length of the legs to relieve tension on the lower back. The use of an overhead trapeze is contraindicated during the 48 hours after surgery because its use could result in twisting of the spine.

A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action?

Insert the catheter 2.5 to 5 cm and inflate the balloon The catheter's balloon is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space in which to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could inflict trauma.

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what?

Moves the cane when the right leg is moved The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches (15 cm) lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side moves forward.

A client tells the nurse that he is feeling fatigued because he must get up several times during the night to urinate. The nurse documents that the client is experiencing which issue?

Nocturia

The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take?

Notify HCP "Enemas until clear" means that the enema is repeated until the client passes fluid that is clear and contains no fecal material. It may be necessary to give as many as three enemas. Excessive enema use seriously depletes fluids and electrolytes. If the fluid fails to return clear after three enemas (check agency policy), the physician should be notified.

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client?

One low in protein

A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning?

Pillow to keep the right leg abducted while turning the client After internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned and proper alignment and abduction are maintained. A trochanter roll or rolled bath blanket is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while the client is being turned.

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication?

Prunes Avocados Nectarines Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client?

urine output will be decreased A febrile client would be expected to have some degree of dehydration resulting from increased metabolic demands. In response to dehydration, the body attempts to restore fluid balance by reducing urine production. The client who is diaphoretic also loses a large amount of fluid through insensible water loss, which worsens dehydration and further decreases urine production. Urine specific gravity is increased in the presence of dehydration; serum osmolality also increases, indicating hemoconcentration related to dehydration.

A nurse is following a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse expect to see included in the plan?

Encouraging coughing and deep breathing

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness?

400 ml With approximately 400 mL of urine in the bladder, the client will feel a sensation of bladder fullness. This amount may be altered by habit and may differ slightly from person to person.

A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan?

Providing privacy and time for defecation Assisting the client into a sitting position Initiating defecation measures every day at the same time Administering a cathartic suppository a half-hour before defecation time A bowel training program can help clients who still have some neuromuscular control after a stroke achieve control of bowel reflexes and have normal defecation. The cornerstone of such a training program is a daily routine. First the client should be encouraged to attempt to defecate at the same time each day after the trigger meal. Other measures include administering a daily stool softener or a cathartic suppository at least a half-hour before defecation time, providing a hot drink or juice that will stimulate peristalsis before defecation time, providing privacy and time for defecation, and assisting the client into a position that will facilitate defecation (e.g., a sitting position). Dietary measures that can help the client achieve bowel-training success include increased fiber intake (with the aim of 25 to 30 g of dietary fiber per day) and adequate dietary fluid intake.

A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed?

The client should move the cane and the affected side together. The cane helps support the affected side as it moves forward. It also helps the client maintain balance. The client holds the cane close to the body to keep from leaning. The client holds the cane on the unaffected side to shift the client's weight away from the affected side. The cane's handle should reach the level of the greater trochanter of the client's femur, with 25 to 30 degrees flexion at the client's elbow.

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)

client who has undergone colectomy A client with acute pancreatitis A client who has undergone gastrectomy A PCA pump contains a cartridge or syringe that holds the prescribed pain medication. The client pushes a button to administer a dose of the medication within limitations prescribed by the health care provider. The client must be able to understand the use of the equipment and be physically able to locate and press the button to deliver the dose. Clients who are confused and unresponsive, those with neurological disease, and those with impaired renal or pulmonary functions are not candidates for PCA.

A nurse notes that a client has a diagnosis of acute back pain. The nurse understands that which is a characteristic of acute pain?

A result of injury

A client has a serum sodium level of 151 mEq/L, and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction?

American cheese

A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client?

Apple juice Chicken broth Orange gelatin

The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the UAP doing which?

Asking the client to wash his arms A complete bed bath is for clients who are totally dependent and require total hygiene care. Total care may be necessary for a client recovering from a myocardial infarction as a means of conserving client energy and reduce oxygen requirements. The nurse would intervene if the CNA asked the client to wash his arms.

A client requires a partial bed bath. The nurse, giving instructions to a nursing assistant about the bath, tells the nursing assistant to take which action?

Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor.

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take?

Clamp the enema bag tubing If the client complains of cramping during instillation of the enema solution, the nurse should either reduce the height of the enema bag or clamp the tubing. Temporary cessation of instillation will alleviate the cramping. Raising the enema bag to quickly finish instillation of the solution will worsen cramping. Removing the enema tube and allowing the client to rest and stopping the instillation and allowing the client to expel the solution will each alter the effectiveness of the enema.

A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse should take which action?

Continue the digital removal procedure.

A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action?

Document the results Tap water is hypotonic, exerting a lower osmotic pressure than fluid in the interstitial space. After infusion into the colon, tap water escapes from the bowel lumen into the interstitial space. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Tap water enemas should not be repeated, because water toxicity or circulatory overload may occur if a large amount of water is absorbed. Therefore the other options are incorrect. Also, the nurse would not administer an additional enema, a soap suds enema, or a Fleet enema without a specific prescription to do so.

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period?

High in Fiber When a client's diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also important. A low-fat diet may be healthy but is not specific to this disorder. A high-carbohydrate diet is not helpful for the client with this condition.

A nurse is monitoring a client's fluid balance. Which 24-hour intake and output total indicates to the nurse that the client has the proper fluid balance?

Intake 1500 mL, output 1400 mL

A client asks a nurse about complementary and alternative measures to promote sleep. What does the nurse suggest?

Muscle relaxation techniques

A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz (240 ml) of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt?

Omitting 8 oz (240 ml) of skim milk from that meal Yogurt is a milk product. Therefore if the client is going to eat 8 oz (240 ml) of yogurt at a meal, the client should eliminate the milk product from the same meal. Ice cream is not recommended for the diabetic diet because it is high in fat and sugar.

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray?

Peas In general, flavorful, warm, or well-chilled foods with texture stimulate the swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, stringy vegetables, and those with skin, such as corn and peas are foods commonly excluded from the diet of a client with dysphagia.

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat?

Spinach Broccoli Cabbage in vitamin K.

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information?

Yogurt Parsley Cranberry juice Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction?

"My risk for malnourishment is much higher while I'm pregnant." Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.

A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem?

Injury to the nerves When crutches are correctly fitted, the tops are three to four fingerbreadths, or 1 to 2 inches (2.5 to 5 cm), from the axillae. This ensures that the client's axillae are not resting on the crutches or bearing the weight of the crutches, which could result in injury to the nerves of the brachial plexus.

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client?

Lentils Raisins Kidney beans The client with iron-deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources are kidney beans, soybeans, lentils, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine?

Plums Prunes Cranberries Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine.

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys?

Release of dopamine Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow.

A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client?

Retain the enema for several hours Oil retention enemas lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. The amount of enema solution is small, and the client usually does not experience cramping. To enhance the action of the oil, the client should retain the enema for several hours, if possible.

A client about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. The nurse should provide the client with which information?

The client administers his own medication by pressing a control button

nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply.

The client should use both crutches when navigating stairs. It is not safe to use someone else's crutches

A client with heart failure and hypertension who has been admitted to the hospital is unable to make her own selections from the menu. Which meals does the nurse select for the client's supper on the day of admission?

Turkey, baked potato, salad with oil and vinegar

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions?

Roast turkey with a baked potato

A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag?

18 inches (45.5 cm) The health care provider may prescribe a high or a low cleansing enema. In this context, high and low refer to the height of the enema bag and hence the pressure at which the fluid is delivered. High enemas are given to cleanse the entire colon. A low enema cleans only the rectum and sigmoid colon. With a high enema, the bag is raised 12 to 18 inches (30.5 to 45.5 cm) or slightly higher above the hips. With a low enema, the nurse holds the bag 3 inches (7.5 cm) or less above the client's hips.

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught?

Spaghetti with fresh tomatoes Grilled chicken with turnip greens

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client?

Beef Chemotherapy may distort how certain foods taste to the client. Beef and pork are often reported by people undergoing chemotherapy to taste bitter or metallic. The nurse can promote nutrition by helping the client choose alternative sources of protein.

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions?

Boiled Potatoes During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and foods such as raw fruits and some vegetables, that are very high in fiber. Vitamins and iron supplements may be prescribed.

Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet?

Bran Spinach The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, all of which may limit calcium absorption. Good dietary sources of calcium include milk products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.

A client arrives at the urgent care center after sustaining an ankle injury, and the health care provider prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, examines the ankle and notes that it is extremely edematous. The nurse should take which action?

Consult with the HCP before applying the cold compress Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid. For this reason, applying the cold compress to the ankle and elevating the ankle and placing a cold compress under and on top of the ankle are both incorrect. The nurse would not place heat on an injury without a prescription to do so. The nurse would consult with the HCP about the prescription for cold application.

A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, most appropriately asks the client whether she has been involved in which activity?

Drinking an excessive amount of coffee

A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines that the client has which issue?

Has a diminished capacity to form urine

A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for?

Lactose

A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which manner?

Left hand, 6 inches lateral to the left foot

A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney?

Loop of Henle Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle.

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine?

Peas Broccoli Potatoes Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits, including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.

A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication?

Rhubarb When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through which routes?

Skin and mechanical ventilator Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur on a daily basis, without the client's awareness. Sensible losses are those that are measurable; they include wound drainage, gastrointestinal tract losses, and urine output.

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information?

The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age Infants and young children are unable to control defecation because of a lack of neuromuscular development. This development usually does not take place until 2 to 3 years of age. A child's letting the parent know when he or she is ready to begin bowel training is not a sign of readiness. There is no difference between neuromuscular development in girls and that in boys.

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction?

To increase the intake of legumes Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.

A nurse is preparing a list of measures that will help promote sleep. Identify the measures that would be included on the list. Select all that apply.

Adjust the room temperature to a comfortable level. Eliminate lights, noise, and other environmental distractions. Get up at the same time each day, and avoid naps during the day.

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply.

Avocados Green olives Cream cheese

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure?

Slightly elevating the foot of the bed In Buck's extension traction, the counter traction is typically applied with the use of the client's body and may be augmented through elevation of the foot of the bed. Usually the foot of the bed is elevated on blocks or the bed is put in the Trendelenburg position. For counter traction to be maintained, it is essential that the client not slide down in the bed. Therefore the use of the high Fowler position is discouraged. A footboard is not used for the purpose of counter traction.

A nurse is caring for a client who has just returned from a cardiac catheterization through the right femoral artery. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which actions should the nurse take to stimulate the client's micturition reflex?

Turning on the water in the sink in the client's room and allowing it to run

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet?

Vitamin B12

A client recovering from acute renal failure is being discharged home. The nurse knows that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which nutrient?

potassium

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application?

An older client Older clients have diminished sensitivity to pain and are therefore at great risk for injury from heat or cold applications. Other clients at risk for injury are the very young; those with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the client with diabetes mellitus; and those who are confused or unconscious.

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee?

Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting The nurse helps the client get out of bed after putting a knee immobilizer on the affected joint for stability. A compression dressing (a.k.a. elastic wrap or Ace bandage) is usually applied after the surgical procedure is complete. The surgeon prescribes weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in a chair to minimize edema. A CPM machine may be prescribed by some surgeons and is used while the client is in bed.

A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond to this via which physiological action?

Increase sodium excretion A serum potassium level of 5.8 mEq/L (5.8 mmol/L) is high, indicating potassium retention associated with the use of the potassium-retaining diuretic. When potassium is retained, the kidneys excrete more sodium.

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction?

Scallops Chicken Liver

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother?

That a child cannot begin to control urination until approximately the age of 24 months A child cannot control micturition voluntarily until he or she is approximately 24 months old. A child must be able to recognize the feeling of bladder fullness, to hold urine for 1 to 2 hours, and to communicate the sense of urgency to an adult. Telling the mother that her child is too young and to not be worrying about bladder training is a nontherapeutic response because it provides false reassurance and places the mother's issue on hold. Bowel control develops before bladder control; however, 1 year of age is too early for the mother to begin elimination training.

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication?

volume of urine output frequency of bowel movements Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse effects include hypotension and slowed respiration.