HSOR module 7 exam
A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client? Select all that apply. a. Lentils b. Raisins c. Pineapple d. Egg whites e. Kidney beans f. Refined white bread
a. Lentils b. Raisins e. Kidney beans Rationale: 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 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? a. Pillow to keep the right leg abducted while turning the client b. Rolled bath blanket to prevent abduction while turning the client c. Trochanter roll to keep the right leg adducted while turning the client d. Rolled bath blanket to prevent external rotation while turning the client
a. Pillow to keep the right leg abducted while turning the client Rationale: 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.
A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan? Select all that apply. a. Providing privacy and time for defecation b. Assisting the client into a sitting position c. Limiting the amount of fiber in the client's diet d. Providing a cool drink before defecation time e. Initiating defecation measures every day at the same time f. Administering a cathartic suppository a half-hour before defecation time
a. Providing privacy and time for defecation b. Assisting the client into a sitting position e. Initiating defecation measures every day at the same time f. Administering a cathartic suppository a half-hour before defecation time Rationale: 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 provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? a. Roast turkey with a baked potato b. Fruit plate with fresh whipped cream c. Fried chicken with macaroni and cheese d. Barbecued spare ribs with buttered noodles
a. Roast turkey with a baked potato Rationale: The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. Therefore the correct answer is roast turkey with a baked potato, which is a meal low in fat.
A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? a. To increase the intake of legumes b. That seafood should be included in the diet c. That organ meats should be included in the diet d. To have at least one serving each day of a citrus fruit
a. To increase the intake of legumes Rationale: 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 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? a. Urine output will be decreased b. Urine production will be increased c. Serum osmolality will be decreased d. Urine specific gravity will decreased
a. Urine output will be decreased Rationale: 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 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? a. Increased sodium retention b. Increased sodium excretion c. Increased glucose retention d. Increased magnesium excretion
b. Increased sodium excretion Rationale: 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. The other options do not correctly reflect the relationship between these two electrolytes.
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 that may be causing this problem? a. Maltose b. Lactose c. Sucrose d. Fructose
b. Lactose Rationale: Several tube-feeding formulas contain lactose. A client with a history of lactose intolerance would experience the symptoms identified in the question if one of these formulas were administered. If the client is found to be lactose intolerant, the health care provider should prescribe a lactose-free formula. This will resolve the client's symptoms and promote adequate nutrition for the client.
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? a. 1½ inches (3.8 cm) b. 3 inches (7.5 cm) c. 4 inches (10 cm) d. 6 inches (15 cm)
c. 4 inches (10 cm) Rationale: 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 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? a. Milk b. Cabbage c. Boiled potatoes d. Coffee with cream
c. Boiled potatoes Rationale: 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.
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? a. Spare ribs, rice, gelatin, tea b. Pasta, garlic bread, ginger ale c. Chicken breast, broccoli, strawberries, milk d. Peanut butter and jelly sandwich, chocolate cake, tea
c. Chicken breast, broccoli, strawberries, milk Rationale: 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 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? a. Contact the health care provider b. Discontinue the digital removal procedure c. Continue the digital removal procedure d. Wait 1 hour and then continue the digital removal procedure
c. Continue the digital removal procedure Rationale: Excessive rectal manipulation may cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which may result in a reflexive slowing of the heart rate. The nurse would reassess the client's heart rate during the procedure. If the heart rate drops significantly or the cardiac rhythm changes, the nurse must stop the procedure. A change in heart rate from 88 to 82 beats per minute is not significant; therefore the nurse would continue the procedure.
A 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? a. Pork b. Beef c. Eggs d. Raisins
c. Eggs Rationale: 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.
A nurse develops 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 include in the plan? a. Encouraging oral fluid intake b. Maintaining the client in a supine position c. Encouraging coughing and deep breathing d. Administering the morphine sulfate around the clock
c. Encouraging coughing and deep breathing Rationale: Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk for atelectasis and subsequent pneumonia. The client should be encouraged to cough and deep-breathe to prevent these postoperative complications. Keeping the client supine is counterproductive and could lead to atelectasis. Adequate fluid intake helps liquefy secretions, making their expulsion easier, but does not prevent atelectasis unless coughing and deep breathing is also performed. Because the medication is prescribed as needed, it would not be administered around the clock.
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? Select all that apply. a. Carrots b. Tapioca c. Scallops d. Broccoli e. Chicken liver
c. Scallops e. Chicken Liver Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.
A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag? a. 4 inches (10 cm) b. 8 inches (20 cm) c. 10 inches (25.5 cm) d. 18 inches (45.5 cm)
d. 18 inches (45.5 cm) Rationale: 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.
A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all that apply. a. Exercise just before bedtime. b. Drink a glass of wine at bedtime. c. Drink a cup (236 ml) of black tea before bedtime d. Adjust the room temperature to a comfortable level. e. Eliminate lights, noise, and other environmental distractions. f. Get up at the same time each day and avoid naps during the day.
d. Adjust the room temperature to a comfortable level. e. Eliminate lights, noise, and other environmental distractions. f. Get up at the same time each day and avoid naps during the day. Rationale: A variety of measures may be used to promote and enhance sleep. These measures include avoiding caffeinated beverages (caffeine is a stimulant) for at least 2 hours before bedtime, avoiding alcohol, maintaining a regular exercise schedule but not exercising immediately before bedtime, getting up at the same time each day, avoiding naps during the day, adjusting the room temperature to a comfortable level, and eliminating lights, noise, and other environmental distractions. Alcohol can lighten and fragment sleep. Exercising just before bedtime promotes stimulation and may prevent sleep. Black tea contains caffeine.
A client has a serum sodium level of 151 mEq/L (151 mmol/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? a. Fish b. Spinach c. Rhubarb d. American cheese
d. American cheese Rationale: The client's laboratory value reflects hypernatremia; the normal serum sodium range is 135 to 145 mEq/L (135-145 mmol/L). On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods from animal sources, which contain physiological saline (e.g., cheese, highly processed meats), and other foods that have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus.
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 hould provide the clent with which information about a cold pack? a. Reduces muscle tension b. Dilates the blood vessels c. Promotes muscle relaxation d. Reduces blood flow to the extremity
d. Reduces blood flow to the extremity Rationale: The application of cold reduces blood flow through its vasoconstriction action and eases localized pain. Cold also reduces the oxygen need of the tissues and promotes blood coagulation at the site of injury. The incorrect options are the effects of heat application.
A home care nurse makes a visit to a new mother who delivered a 7-lb (3.1 kg) girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother? a. "Most newborns sleep about 16 hours a day" b. "We should probably have the baby checked out by the doctor." c. "If you see any other neurological alterations, call the pediatrician." d. "It's important to wake the baby every hour to provide stimulation."
a. "Most newborns sleep about 16 hours a day" Rationale: Between birth and 3 months, an infant averages 16 hours of sleep a day. Therefore this newborn's sleep pattern is normal. It is not necessary to wake the newborn every hour to provide stimulation.
The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? a. A client with osteoarthritis b. A client with angina pectoris c. A client who has undergone appendectomy d. A client with a leg fracture who is in skeletal traction
a. A client with osteoarthritis Rationale: Chronic pain is associated with chronic disease. The pain is prolonged, varies in intensity, and lasts longer than 6 months. The incorrect options are clients who are likely to experience acute pain.
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? Select all that apply. a. Plums b. Prunes c. Apples d. Broccoli e. Cabbage f. Cranberries
a. Plums b. Prunes f. Cranberries Rationale: 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. The incorrect options are not food items that will acidify the urine.
Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication? Select all that apply. a. Volume of urine output b. Strength of peripheral pulses c. Ability to move the extremities d. Frequency of bowel movements e. Color, motion, and sensation of extremities
a. Volume of urine output d. Frequency of bowel movements Rationale: 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. The incorrect options are not specifically associated with this medication.
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? a. 2 inches (5 cm) to the front and side of the toes b. 8 inches (20 cm) to the front and side of the toes c. 15 inches (38 cm) to the front and side of the toes d. 22 inches (56 cm) to the front and side of the toes.
b. 8 inches (20 cm) to the front and side of the toes Rationale: 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. The remaining options are incorrect.
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? Select all that apply. a. Lettuce b. Cherries Correct c. Broccoli d. Cabbage e. Potatoes Correct f. Spaghetti Correct
b. Cherries e. Potatoes f. Spaghetti Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as lettuce, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K.
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? a. Wound drain and skin b. Skin and mechanical ventilator c. Nasogastric tube and wound drain d. Foley catheter and nasogastric tube
b. Skin and mechanical ventilator Rationale: 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 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? Select all that apply. a. Eggs b. Yogurt c. Parsley d. Broccoli e. Cucumbers f. Cranberry juice
b. Yogurt c. Parsley f. Cranberry juice Rationale: 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.
An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? a. She should avoid napping during the day b. The only thing that will help is a sleeping pill c. This is a normal occurrence as a person gets older d. She needs to stay up later at night to prevent these awakenings
c. This is a normal occurrence as a person gets older Rationale: The total amount of sleep a person needs does not change with increasing age. However, the quality of sleep appears to deteriorate for many older adults, giving rise to complaints of feeling less rested. An older adult awakens more often during the night than a younger person does, and it may take an older adult longer to fall asleep. Therefore the other options are incorrect. Additionally, measures other than medication should be implemented to promote rest and sleep.
A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered? a. 250 mL b. 500 mL c. 750 mL d. 1000 mL
d. 1000 mL Rationale: Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through the infusion of a large volume of solution or local irritation of the colon's mucosa. The maximal volume of solution for an adult is 1000 mL.
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? a. The child should be able to control defecation at the age of 18 months b. The child will let you know when she is ready to begin bowel training c. Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than boys do d. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age
d. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age Rationale: 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.
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply. a. A client who has undergone colectomy b. A client with acute pancreatitis c. A client who has undergone gastrectomy d. A client with renal insufficiency e. A client with Alzheimer's disease
a. A client who has undergone colectomy b. A client with acute pancreatitis c. A client who has undergone gastrectomy Rationale: 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 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? a. Daily weight b. Serum protein level c. Calorie count sheets d. Daily intake and output records
a. Daily weight Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is the daily weight. The client should be weighed at the same time (preferably early morning) each day, wearing the same clothes, on the same scale. The incorrect options may be used to assess nutrition and hydration status, but the effectiveness of the diet is measured by whether the client's body weight is maintained.
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? a. One low in protein b. One high in fluids c. One high in carbohydrates d. One with a moderate amount of fat
a. One low in protein Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the formation of ammonia. Therefore the client would benefit from a low-protein diet.
A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain? a. It has a prolonged presence b. It is a result of injury c. It lasts longer than 6 months d. It is usually the result of a chronic disorder
b. It is a result of injury Rationale: Acute pain follows acute injury, disease, or surgical intervention and is rapid in onset and variable in intensity (mild to severe). It lasts a brief time, usually less than 6 months. The incorrect options are descriptions of chronic pain.
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? a. Not eating ice cream for 2 days b. Omitting 8 oz (240 ml) of skim milk from that meal c. Omitting salad dressing and butter at lunchtime d. Eating only half of an allowed meat product at supper
b. Omitting 8 oz (240 ml) of skim milk from that meal Rationale: 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. Meat is not a milk product, and it is unnecessary to alter the meat allowance at suppertime. Salad dressing and butter are fats.
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? a. Physiological stress b. Release of dopamine c. Release of norepinephrine d. Sympathetic nervous system stimulation
b. Release of dopamine Rationale: Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow. The factors set forth in the other options result in renal vasoconstriction.
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? a. That she may start bladder training at any time b. That her child is too young and that she should not yet be worrying about it c. That a child cannot begin to control urination until approximately the age of 24 months d. That bowel training should be started immediately and then begin bladder training in about 1 month
c. That a child cannot begin to control urination until approximately the age of 24 months Rationale: 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.
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? a. Giving the client a complete bed bath b. Pulling the room curtains around the bathing area c. Turning up the thermostat in the client's room for the bath d. Keeping the side rails (per agency policy) up while away from the client
a. Giving the client a complete bed bath Rationale: 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 instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply. a. It is not safe to use someone else's crutches. b. Rubber crutch tips will not slip, even when wet. c. The client should use both crutches when navigating stairs. d. Lean into the crutches as needed to support the body's weight. e. Crutch tips are made of a material that will not wear down.
a. It is not safe to use someone else's crutches. c. The client should use both crutches when navigating stairs. Rationale: The client should use only crutches that have been measured and set for him. When ascending or descending stairs, the client generally uses a three-phase sequence involving both crutches. Crutch tips should be kept as dry as possible. Water could cause slippage by reducing the friction of the rubber tip against the floor. If the tips get wet, the client should dry them with a cloth or paper towel. The tips should be inspected for wear, and spare crutches and tips should be available. Leaning into the crutches to support the body's weight increases the risk of axillary nerve injury.
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? a. Left heel b. Scapulae c. Right heel d. Back of the head
c. Right heel Rationale: 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.
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? a. Low in fat b. High in fiber c. Low in residue d. High in carbohydrates
b. High in fiber Rationale: 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 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? a. Skin breakdown b. Injury to the nerves c. An abnormal stance d. A fall and further injury
b. Injury to the nerves Rationale: 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. The incorrect options are not the primary concerns in this situation.
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? a. Immediately inflate the balloon b. Insert the catheter 2.5 to 5 cm and inflate the balloon c. Wait until the urine flow stops and inflate the balloon d. Insert the catheter until resistance is met and inflate the balloon
b. Insert the catheter 2.5 to 5 cm and inflate the balloon Rationale: 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 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? a. Distal tubule b. Loop of Henle c. Collecting duct d. Proximal tubule
b. Loop of Henle Rationale: Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle. Furosemide does not exert an effect on the areas identified in the other options.
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? a. Holds the cane on the right side b. Moves the cane when the right leg is moved c. Leans on the cane when the right leg moves forward d. Keeps the cane 6 inches (15 cm) out to the side of the right
b. Moves the cane when the right leg is moved Rationale: 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 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? Select all that apply. a. Milk b. Peanuts c. Chicken d. Broccoli e. Asparagus f. Whole-grain cereals
b. Peanuts e. Asparagus f. Whole-grain cereals Rationale: 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 client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? a. Flexing the feet against a footboard b. Slightly elevating the foot of the bed c. Keeping the head of the bed elevated 45 degrees d. Placing the bed in reverse Trendelenburg position
b. Slightly elevating the foot of the bed Rationale: 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 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? a. "I shouldn't lie on the pad." b. "I'll avoid using the high setting." c. "I can pin the pad around the affected area." d. "I'll need to keep an eye on my skin for redness."
c. "I can pin the pad around the affected area." Rationale: 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 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? a. Asking the client to take slow, deep breaths b. Removing the catheter and contacting the health care provider (HCP) c. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon d. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon
c. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon Rationale: 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 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? a. The client holds the cane close to the body b. The client holds the cane on the unaffected side c. The client moves the cane and the unaffected side together d. The client uses the cane to support the affected side and to maintain balance
c. The client moves the cane and the unaffected side together Rationale: 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.
A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client makes which statement? a. "I should bend at the knees to pick things up." b. "I need to increase the fiber and fluids in my diet." c. "I can strengthen my back muscles by swimming or walking." d. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."
d. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed." Rationale: Clients are taught to get out of bed by sliding near the edge of the mattress, then rolling onto one side and pushing up from the bed, using one or both arms. The back is kept straight and the legs are swung over the side. Proper body mechanics includes bending at the knees, not the waist, to lift objects. Increased fluids and fiber in the diet help prevent straining at stool and, in turn, increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening the lower back muscles.
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? a. Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg b. Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting c. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. d. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting
d. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting Rationale: 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.
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? a. Washing the client's feet b. Washing the client's chest c. Giving the client a back rub d. Asking the client to wash his arms
d. Asking the client to wash his arms Rationale: 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. The other options are components of a complete bed bath.
A nurse asks an unlicensed assistive personnel (UAP) to provide afternoon care to a client. The nurse expects that the UAP will take which action? a. Give the client a complete bed bath b. Ask the client whether he would like to wash his face c. Give the client a back massage and prepare the client for sleep d. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens
d. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens Rationale: Afternoon hygiene care includes washing the client's hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens. It does not involve giving a complete bed bath. Giving the client a back massage and preparing the client for sleep are components of evening or hour-before-sleep care. Asking the client whether he would like to wash his face encourages independence but is not one of the components of afternoon care.
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 clientwill experience which? a. Become totally unaware of pain b. Ignore the pain by focusing on the alternate activity c. Alter pain perception though the influence of positive suggestion d. Become less aware of pain by creating and then concentrating on a mental image
d. Become less aware of pain by creating and then concentrating on a mental image Rationale: In guided imagery, the client creates a mental image and then concentrates on the image, becoming less aware of pain and other stimuli. Hypnosis can help alter pain perception through the influence of positive suggestion. Certain distraction techniques, such as music, can help a client ignore pain. No alternative or complementary therapy will allow the client to become totally unaware of pain.
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 which about the client when planning care? a. Is unable to produce urine b. Is voiding large amounts of urine c. Has difficulty with leakage of urine d. Has a diminished capacity to form urine
d. Has a diminished capacity to form urine Rationale: Oliguria, diminished capacity to form urine, is most often the result of a decrease in renal perfusion. Anuria is the inability to produce urine. Polyuria is the voiding of excessively large amounts of urine. Urinary incontinence is the involuntary loss of urine.
A nurse is preparing to administer an enema to a client. In which position does the nurse place the client?
Left-lying Sims position Rationale: When an enema is administered, the client is placed in the left-lying Sims position so that the enema solution may flow by way of gravity in the natural direction of the colon. Although the knee-chest position does provide exposure to the rectal area, the position is uncomfortable and embarrassing for the client. The supine and the prone positions do not provide adequate exposure or promote gravity flow in the natural direction of the colon.
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? Select all that apply. a. Lying down after eating b. Eating high-protein foods c. Drinking liquids with meals d. Eating six small meals per day e. Eating concentrated sweets during the day
a. Lying down after eating b. Eating high-protein foods d. Eating six small meals per day Rationale: The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbohydrates. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.
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? a. Notify the HCP b. Continue administering enemas until the fluid returns clear c. Administer a glycerin suppository and then administer one more enema d. Allow the client to rest for 1 hour and then continue with another enema
a. Notify the HCP Rationale: "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. Therefore the other options are incorrect.
A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? a. Smoked ham, fresh carrots, boiled potato b. Hot dog in a bun, sauerkraut, baked beans c. Turkey, baked potato, salad with oil and vinegar d. Shrimp, baked potato, salad with blue cheese dressing
c. Turkey, baked potato, salad with oil and vinegar Rationale: Foods that are high in sodium should be limited in the diet of the client with hypertension and heart failure. Foods in the meat group that are higher in sodium include bacon, luncheon meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for hypertensive clients.
