Lesson 5: Basic Care & Comfort

During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP) had an IV fluid intake of 1,200 mL, an oral intake of 400 mL, continuous bladder irrigation of 2,400 mL, two antibiotic piggybacks of 50 mL each and an indwelling urinary catheter output of 3,000 mL.

Correct Answer: 1100 mL Rationale: The amount of irrigation fluid must be included in the client's intake. Only the urine collected from the indwelling urinary catheter is considered output. 1200mL+400mL+2400mL+50mL+50mL=4100mL 4100mL-3000mL=1100(or-1100)mL net output, or I/O balance.

The client is grimacing, crying and reports having pain. What is the first step the nurse should take when collecting data about the client's pain? A. Accept the client's report of pain. B. Inquire about the client's goal for pain relief. C. Determine any aggravating factors of the pain. D. Ask the client to describe the pain's quality and location

Correct Answer: A Rationale: Although all of the actions are correct, the first and most important aspect of pain management is for the nurse to accept that the client is in pain and the pain is as severe as the client reports it to be. Pain is a subjective phenomenon and only the person experiencing it can confirm its presence and severity. Pain can exist even if no physical cause is apparent.

The nurse explains a low cholesterol diet to a client diagnosed with heart disease. Which menu selection by the client demonstrates that the client understands the teaching? A. Turkey chili made with kidney beans B. Shrimp and pasta C. Sausage with peppers and fried potatoes D. Fried chicken and macaroni and cheese

Correct Answer: A Rationale: Cholesterol is a fat-like substance found only in animal products. It is not an essential nutrient. The body makes enough good cholesterol (HDL). The American Diabetes Association (ADA) recommends limiting the total intake of dietary cholesterol to less than 300 mg/day. This may help reduce risk factors, such as increased serum cholesterol levels, which are associated with the development of coronary artery disease. Different foods lower cholesterol in various ways. Some deliver soluble fiber, which binds cholesterol and its precursors in the digestive system and drags them out of the body before they get into circulation. Some deliver polyunsaturated fats, which directly lowers bad cholesterol (LDL). Some contain plant sterols and stanols, which block the body from absorbing cholesterol. Canned chicken, unsalted butter and scrambled eggs are all products derived from animals. Legumes are plant based and are especially rich in soluble fiber.

A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? A. Continue a regular diet and add electrolyte replacement drinks. B. Keep the child fasting, give them nothing to eat, and return the next day. C. Give the child bananas, apples, rice and toast as tolerated. D. Give the child only clear liquids and gelatin for 24 hours.

Correct Answer: A Rationale: Current recommendations for mild to moderate diarrhea are to maintain an age-appropriate diet and include rehydration fluids that contain electrolytes. Some providers now recommend a diet of cereal, rice and milk (the C.R.A.M. diet) because milk provides fat and protein and the C.R.A.M. foods are shown to ease diarrhea quickly. The B.R.A.T. diet, consisting of bananas, rice, applesauce and toast or tea, should be avoided for children with acute gastroenteritis because it is low in energy foods, protein and fat. Both the C.R.A.M. and B.R.A.T. diets require oral hydration therapy. The other recommendations are incorrect.

The nurse documents the following in the client's medical record: "Effective use of guided imagery to change report of pain from a level of 4 to 1 on the numeric pain scale." Which definition best describes this non-pharmacological technique? A. Focusing on pleasant mental pictures of a relaxing scene. B. Closing the eyes or focusing on a blank screen. C. Inhaling on a count of four and exhaling on a count of four. D. Repeating a word while thinking only of the word.

Correct Answer: A Rationale: Guided imagery is a non-pharmacologic technique that uses pleasant mental visuals of a relaxing scene, which can be recalled by the client to reduce stress, anxiety or pain. Repeating a word to oneself describes meditation. Closing the eyes or focusing on a blank screen is another form of meditation, in which a person uses a mental picture of a blank black screen and attempts to think of nothing. Counting while breathing is considered slow deep breathing.

The nurse is monitoring a UAP as they provide perineal care to a client who suffers from urinary incontinence. What action by the UAP would require intervention by the nurse? A. The UAP cleanses the urinary meatus and then the labia majora and minora. B. The UAP removes the towel under the client once care is complete. C. The UAP utilizes a clean washcloth to wipe from anterior to posterior. D. The UAP provides perineal care after each episode of incontinence.

Correct Answer: A Rationale: It is critical that the UAP provides appropriate care, which reduces the risk of infection and loss of skin integrity. Perineal care should be performed by cleansing from anterior to posterior and outside to inside. This should be done using a clean portion of the washcloth for each wipe. Cleansing the urinary meatus and then the labia majora and minora increases the risk of spreading microorganisms from the protective structures of the labia to the urinary meatus.

The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? A. Keep conversations short. B. Encourage visits from family and friends. C. Monitor vital signs frequently. D. Increase the client's oral fluid intake.

Correct Answer: A Rationale: Keeping conversations short will promote the older adult client's comfort by decreasing the demands on the client's breathing and energy. Increased intake of fluids is not related to the client's comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client's need for rest. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.

The nurse is caring for a client who is recovering from a right total hip arthroplasty. The client reports a sudden onset of chest pain and difficulty breathing. What action should the nurse take first? A. Elevate the head of the bed. B. Notify the health care provider. C. Obtain the client's vital signs. D. Auscultate the client's lung fields.

Correct Answer: A Rationale: The client is exhibiting clinical manifestations of a pulmonary embolism (PE). A PE is a medical emergency, which requires immediate action from the nurse. Deep vein thromboses (DVTs) can occur after a total hip arthroplasty due to immobilization during and after surgery. By elevating the head of the bed, the nurse will decrease dyspnea associated with the PE. The nurse should then assess the client and report the clinical manifestations to the HCP.

Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? A. The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. B. The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client. C. The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection. D. The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection.

Correct Answer: A Rationale: The nurse should advocate for clients by requesting removal of an indwelling urinary catheter as soon as possible to reduce the risk of catheter-associated urinary tract infections (CAUTI). C. difficile bacteria is not killed by alcohol-based preparations and the nurse should wash their hands for 60 seconds or more with soap and water. Clients with a VRE infection should be placed in contact precautions, which require the use of personal protective equipment (PPE), including a gown and gloves. A client in contact precautions should, ideally, have dedicated equipment such as a disposable stethoscope and blood pressure cuff placed in the room for the nurse, unlicensed assistive personnel (UAP) or HCP to use. The nurse should keep their own stethoscope out of the room to reduce the risk of contamination and transmitting the infection to other clients.

A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? A. Orient the client to the unit. B. Take the client's vital signs. C. Review the postoperative orders. D. Ask the client about pain.

Correct Answer: B Rationale: Although all these actions are appropriate, the first assessment or data collected should be the client's vital signs. After surgery, a client may still experience side effects from the surgery and the anesthetic agents used. Therefore, vital signs provide important information about the client's hemodynamic and respiratory status. Then, the nurse should evaluate the client's level of pain and implement interventions to alleviate the client's pain.

A nurse is caring for a client who is receiving enteral nutrition. Before starting the next bolus feeding, what action should the nurse take? A. Elevate the head of the bed to 90°. B. Verify correct tube placement. C. Add food dye (color) to the tube feeding. D. Irrigate the feeding tube vigorously.

Correct Answer: B Rationale: Before the nurse administers anything through a feeding tube, they need to verify correct placement of the tube. The recommended angle for the head of bed (HOB) while receiving tube feedings is 30 to 45°. It is no longer considered a best practice to add dye or food coloring to tube feeding as a way to monitor for aspiration. Food coloring has been associated with the development of diarrhea. Irrigation of the tube is not indicated at this time and it should not be done vigorously.

The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? A. A cup of cereal B. A cup of yogurt C. A slice of wheat bread D. An oatmeal cookie

Correct Answer: B Rationale: Celiac disease is an autoimmune disease that occurs in genetically predisposed people, where the ingestion of gluten leads to damage in the small intestine. Gluten is a general name for the proteins found in wheat, rye, barley and triticale (a cross between wheat and rye). Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. Children or adults with celiac disease should eat a gluten-free diet. An oatmeal cookie, wheat bread and cereal contain gluten and should be avoided. Dairy products are generally considered gluten-free and are an appropriate snack choice for the child.

The nurse is reinforcing foot care instructions for a client with a history of arterial insufficiency in the legs. Which client statement should the nurse identify as incorrect? A. "I should not walk barefoot around my house." B. "I will use Epsom salt to remove any corns and calluses." C. "I will ask a family member to help inspect my feet." D. "I should wear absorbent cotton socks."

Correct Answer: B Rationale: Clients who have peripheral arterial vascular disease suffer from decreased circulation and sensation to the lower legs and feet. Appropriate and regular foot care is very important to prevent integumentary complications. The client should not use commercial preparations or home remedies such as magnesium sulfate, the active ingredient in Epsom salt, to remove calluses or corns. Whenever possible, the client should have a professional inspect and remove any calluses or corns.

The nurse in a health clinic is reviewing recommended nutritional therapy with a client who has a history of emphysema. Which action should the nurse emphasize to the client? A. Perform exercises to enhance appetite. B. Use oxygen during meals. C. Use the rescue inhaler prior to meals. D. Drink lots of liquids with meals.

Correct Answer: B Rationale: Clients with emphysema often experience shortness of breath or "air hunger" while eating. Giving the client oxygen through a nasal cannula will alleviate the air hunger while eating. Clients should avoid drinking a lot of fluids with meals to prevent gastric distention, which can worsen the shortness of breath as well as make the client feel full too soon. Engaging in exercise before eating is not recommended, since it can worsen the shortness of breath and decrease appetite. A rescue inhaler should not be used routinely but should be reserved for episodes of acute respiratory distress.

An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action? A. A heart rate of 110 bpm B. A bladder ultrasound value of 900 mL C. Severe abdominal pain D. A blood pressure of 180/105

Correct Answer: B Rationale: Complications of BPH include acute urinary retention. Urinary retention is the accumulation of urine in the bladder due to bladder outlet obstruction caused by the enlarged prostate gland. Acute urinary retention is a medical emergency that requires prompt bladder drainage. The elevated heart rate and blood pressure and the severe abdominal pain are signs and symptoms of the acute retention. They will most likely resolve when the retention is resolved. The high bladder scan/ultrasound value confirms the retention of a large volume of urine that will require catheterization.

A client is admitted for hypovolemia associated with multiple draining wounds. Which is the best method for the nurse to use to evaluate the client's fluid balance? A. Presence of edema B. Daily weight C. Hourly urine output D. Skin turgor

Correct Answer: B Rationale: Daily weight is the most easily obtained and accurate means of assessing a client's fluid volume status. Skin turgor varies considerably with age. Marked excess fluid volume may already be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take into account fluid intake or fluid loss through insensible loss, sweating or loss from the gastrointestinal (GI) tract or wounds.

The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? A. Moist oral mucus membranes B. Urine output of 35 mL per hour C. Elastic, nontenting skin turgor D. No reports of thirst

Correct Answer: B Rationale: Resuscitation for a severe burn requires large fluid volume replacement in a short time to maintain blood flow to vital organs. Monitoring client responses is critical to determine the adequacy of resuscitation for hydration and blood perfusion of the brain, heart and kidneys. Urine output is the most common and sensitive noninvasive assessment parameter for cardiac output and tissue perfusion. The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult.

The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider? A. Blood glucose level of 146 mg/dL B. Serum creatinine level of 2.8 mg/dL C. Serum potassium level of 5.0 mEq/L D. Serum hemoglobin level of 15.7 g/dL

Correct Answer: B Rationale: The client with dehydration will show certain increased lab values that are due to hemoconcentration - an imbalance in the ratio of plasma to solutes in the blood. Dehydration will cause a decrease in fluid, i.e., plasma, in the blood. This decrease will make the concentration of solutes such as glucose, potassium and hemoglobin appear higher than they actually are. Creatinine is excreted solely by the kidneys and is proportional to renal function. Thus, with normally functioning kidneys, the creatinine level should remain within a normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result for the nurse to report to the HCP.

The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching? A. Vegetable pizza and ice cream B. Cheeseburger and baked potato chips C. Leftover turkey on a sandwich and fresh pineapple D. Grilled cheese sandwich with a glass of skim milk

Correct Answer: C Rationale: Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess. A sodium-restricted diet should consist of less than 2 grams of sodium per day. (A regular diet should include 4 to 6 grams of sodium per day.) A turkey sandwich is the healthiest meat choice and fresh pineapple is low in sodium. Any food with more than 480 mg of sodium per serving, such as pizza, processed cheese or meats, are considered high-sodium foods and should be avoided.

The nurse is caring for a client with paraplegia due to a spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client? A. Consult with the discharge planner about equipment the client's needs at home. B. Observe the client performing self-catheterization correctly. C. Obtain a pressure-reducing mattress for the client's bed. D. Encourage the client to increase intake of fluids and high-fiber foods.

Correct Answer: C Rationale: Clients with a spinal cord injury are at risk for skin breakdown, such as pressure injuries, due to immobility and decreased sensation. A pressure-reducing cushion should be used on the wheelchair and the bed should have an air- or pressure-reducing mattress. The other interventions should also be included, but maintaining skin integrity is the highest priority.

The nurse is monitoring a client who is caring for their prosthetic limb. Which action by the client demonstrates that the client correctly understands prosthetic limb care? A. The client uses baby powder in the prosthetic limb socket. B. The client adjusts the fit of the prosthetic limb using gauze and tape. C. The client dries the inside of the prosthetic socket after wiping it with soap and water. D. The client changes the residual leg sock/stocking once every two days.

Correct Answer: C Rationale: To decrease the risk of irritation and infections, prosthetic limbs should be maintained by keeping the socket clean and dry. Cleaning prosthetic sockets involves using soap and water daily. The client should change the residual leg sock at least daily and only use products prescribed by the primary HCP. Using baby powder is not appropriate. Periodic adjustments of the sizing or fit of a prosthetic limb are expected and should be done by a professional. Using tape and/or gauze to self-adjust the fit of the prosthetic might cause skin irritation and breakdown.

An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? A. Very low-calorie diets are appropriate for long-term weight management. B. Very low-calorie diets are adequate if balanced with fruits and vegetables. C. Very low-calorie diets often have severe and irreversible side effects. D. Very low-calorie diets are intended for short-term use only.

Correct Answer: D Rationale: A very low-calorie diet (VLCD), less than 1,000 calories a day, is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care and supervision of a health care provider (HCP). VLCDs are generally considered safe and common side effects, such as fatigue, constipation or diarrhea, are usually minor and improve within a few weeks. The best way to maintain weight loss though, is through a combination of behavioral therapy, exercise and more modest caloric restrictions of around 1,200 calories per day. Every diet should contain fruits and vegetables, but those foods are low in calories and would not make a VLCD more balanced.

A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? A. Assist the client to drink through a straw. B. Instruct the client to tilt their head back while swallowing. C. Instruct the client to use sips of water to help wash down food. D. Position the client in an upright position while they are eating.

Correct Answer: D Rationale: Dysphagia means difficulty swallowing and it is often associated with a stroke. Clients with dysphagia are at risk of aspirating foods and fluids into their lungs. Interventions that reduce the risk for aspiration include positioning the client in an upright sitting position, offering the client puréed or soft food, thickening liquids (if indicated) and instructing the client to swallow one bite at a time and not mix solid foods with liquid. Straws are contraindicated for clients with dysphagia because they increase the risk of aspiration. The client should tuck in their chin and not tilt their head back to facilitate swallowing and prevent aspiration while they are swallowing.

A client reports to the nurse the passage of hard dry stools at least twice a week. Which of these actions should the nurse suggest that the client take first to improve their bowel function? A. Avoid binding foods, such as cheese. B. Increase physical activity. C. Use a chemical laxative as needed. D. Increase daily fiber intake to at least 20 grams.

Correct Answer: D Rationale: Incorporating high-fiber foods into their diet, especially whole grains, fruits and vegetables, should be the client's first step to improve their bowel function. A regular recommended diet of about 2,000 calories a day should include about 25 grams of fiber. The client should also increase their fluid intake and avoid food that tends to bind or reduce the water content of stool, such as cheese. Although physical activity will promote peristalsis and reduce the risk of constipation, the effect is more indirect and less effective than increasing fiber intake. Laxatives should be used as a last resort.

A client is on NPO status and has a nasogastric (NG) tube in place, connected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? A. Allow the client to melt ice chips in their mouth. B. Provide the client mints to freshen their breath. C. Swab the client's mouth, using glycerin swabs. D. Provide oral care at least every 2 to 4 hours.

Correct Answer: D Rationale: Oral hygiene is an important part of basic client care, especially for clients who are older and/or on NPO status. Regular oral care maintains mucous membrane integrity and prevents oral cavity inflammation or infections. Some clients (e.g., clients who've experienced stroke or trauma to their oral cavity, or a client with an endotracheal tube) require oral care as often as every 1 to 2 hours. Effective oral hygiene include brushing their teeth at least twice a day. For clients at increased risk of poor oral hygiene, use an antimicrobial toothpaste and 0.12% chlorhexidine (CHG) oral rinse. Ice chips are contraindicated for a client who is NPO and has a bowel obstruction. Lemon and glycerin swabs will further dry out mucous membranes and erode tooth enamel and should not be used.

The nurse is reviewing information with a client about their new ileostomy. Which statement by the client suggests that they understand the teaching? A. It is normal to empty my pouch every thirty minutes." B. "It is normal to take a laxative as needed for constipation." C. "It is normal for the skin around my stoma to be irritated." D. "It is normal for my stoma to remain red in color."

Correct Answer: D Rationale: The stoma will remain red in color because it is very vascular. If the client needs to empty the pouch every thirty minutes that would be considered too frequent. A full bowel assessment should be obtained to gather more data. Laxatives are contraindicated with ostomies.

The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client? A. Go jogging 5 to 7 times a week. B. Participate in swimming lessons three times a week. C. Enroll in a kickboxing class twice a week. D. Walk for 30 minutes, 3 to 5 times a week.

Correct Answer: D Rationale: Weight-bearing exercises are beneficial in the prevention and treatment of osteoporosis. Although bone loss cannot be substantially reversed, further loss can be greatly reduced and prevented if the client includes weight-bearing exercises, and vitamin D and calcium supplements in their treatment protocol. In addition to adopting exercises for muscle strengthening, a general weight-bearing exercise program should be implemented. Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention. Remind the client to avoid any activity that would jar the body, such as jogging and horseback riding. These activities can cause compression fractures of the vertebral column. Although swimming can help develop overall muscle strength, it is not as effective in promoting bone density since it is not a weight-bearing activity.

The nurse is reviewing a client's dietary history. The nurse understands that which factors will influence the clients' dietary intake? (Select all that apply.) A. Education B. Personal feelings C. Religion D. Anthropometric measurements E. Culture

Correct Answers: A, B, C, E Rationale: Dietary choices or restrictions are influenced by economics, culture, religion and personal feelings and meanings associated with food. The financial income of the client or the client's household can directly impact the ability to purchase sufficient food and/or food of high nutritional value. Diverse lifestyles and eating habits directly impact a person's nutritional health and well-being. Religious restrictions and beliefs or cultural practices may affect the client's acceptance of, response to and compliance with dietary therapies. Health care providers (HCP) need to understand a client's cultural values, beliefs and practices to provide culturally acceptable care (Taylor, p. 1212). Anthropometric measures are used to measure growth rate, body protein and fat stores. They do not directly influence dietary intake.

A client is placed on a high-protein diet and asks the nurse to describe the role of protein in the body. Which responses by the nurse describe the role of protein? (Select all that apply.) A. "Protein plays a role in the body's immunity." B. "You can determine your protein needs according to your body weight." C. "Protein is necessary for the formation of body structures, including bone, muscle and red blood cells." D. "Protein should be at least 5% of your total daily intake of calories." E. "Wound healing is poor with decreased levels of protein."

Correct Answers: A, B, C, E Rationale: Protein is a vital component of every living cell and is required for the formation of all body structures, including genes, enzymes, muscle, bone matrix, skin and blood. Protein is critical for the structure, function and regulation of the body's tissues and organs. The Acceptable Macronutrient Distribution Range (AMDR) is a recommended percentage of energy intake for carbohydrates, proteins and fats. The AMDR for protein is 10 to 35%; With decreased levels of protein there is a decrease in immune cells. Wound healing is poor and the body is unable to fight off infection because of multiple immunologic malfunctions throughout the body. Protein needs can be determined according to body weight or by using the value of grams per day, which is reliable for most healthy people. As a general guideline, the recommended daily intake of protein is .04 to .06 ounces (1 to 1.8 grams) per 2.2 pounds (.1 kg) of body weight.

The nurse is administering medication to a client who does not speak English. Which of the following strategies should the nurse implement to ensure the client understands the purpose of the medication? (Select all that apply.) A. Maintain eye contact with the client, even when speaking to an interpreter. B. Plan to take a longer amount of time than usual for medication administration. C. Use the translation phone line to interpret information between the client and nurse. D. Use correct medical terminology during instructions. E. Communicate through a facility-approved interpreter.

Correct Answers: A, B, C, E Rationale: There are several tools available for the nurse to help the client who does not speak English. These include translation phone lines and facility-approved interpreters. The nurse should maintain eye contact with the client throughout the communication and should be prepared for the encounter to take additional time. Medical terminology should be kept to a minimum during communication with clients in general, but especially for clients with limited English proficiency.

The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? (Select all that apply.) A. "l will drink no more than 1.5 liters each day." B. "I will push as hard as I can to push out my stool." C. "I will sit on the toilet for a half an hour to try to go to the bathroom." D. "I will make sure that my foods do not have much fiber and are soft." E. "I will make sure to insert my suppository just before bedtime."

Correct Answers: A, B, D, E Rationale: Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. Straining at stool should be avoided due to risk for hemorrhoids.

The nurse is planning the discharge of an 80-year-old female client. Which of the following indicates the client needs to be discharged to a skilled nursing facility instead of home? (Select all that apply.) A. The client has a complex surgical dressing change. B. The client needs intensive rehabilitation after hip replacement surgery. C. The client is afraid to go home by herself. D. The client is able to prepare simple meals by herself. E. The client is not able to manage her activities of daily living (ADL).

Correct Answers: A, B, E Rationale: After a hospital stay, the client may not be able to return to self-care at home and referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a skilled nursing facility include not being able to manage her own ADL and requiring a complex dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility. Being afraid to go home by herself will need to be addressed prior to discharge but is not a criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals, it is a sign that the client could stay at home.

The nurse has given discharge instructions to a client who underwent abdominal surgery. Which of the following statements indicates that the client correctly understands how to manage their pain at home? (Select all that apply.) A. "Before I take an herbal supplement for pain, I should check with my provider." B. "A warm shower before bed might alleviate my pain and help me sleep." C. "My goal for pain relief should be 0/10 on a pain scale." D. "My discomfort should be relieved within 10 minutes of taking my pain pill." E. "Listening to my favorite music might help control my pain."

Correct Answers: A, B, E Rationale: Nonpharmacological pain-relief methods can help maximize the effects of pharmacological therapies and lessen how much medication a client needs for pain control. Music is considered a form of distraction. It can reduce pain, anxiety and depression. Herbal supplements may interact with prescribed analgesics. Clients need to make sure their health care provider is aware of all the medications they currently take. Oral pain medications usually peak within one hour. Moist heat can alleviate muscle tension and reduce pain. Clients should set a reasonable goal for pain control (e.g., 3/10 or 4/10). It is unrealistic to think that a client will have no pain after surgery. They should set a pain relief goal that will allow them to rest, participate in therapy sessions and perform activities of daily living.

The nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions demonstrate that the nurse is advocating for the patient? (Select all that apply.) A. Provide a list of area pharmacies that offer free or reduced-price medications. B. Consult a social worker to help the client apply for Medicaid. C. Arrange for a family member to provide housing for the client. D. Arrange for home delivery of prepared meals. E. Arrange for a follow-up appointment at a free clinic.

Correct Answers: A, B, E Rationale: The nurse as an advocate needs to understand the client's current situation. It would not be possible for a homeless individual to receive scheduled meal delivery services. Family members should not be approached. The nurse could arrange appointments at a free clinic and refer the client to area pharmacies that provide free or reduced-price medications. The social worker should be consulted to help the client apply for Medicaid, as well as for other available social services.

The nurse is reviewing the history of a client with type 2 diabetes mellitus. The client's most recent hemoglobin A1C level was 9.5%. What information about nutritional therapy should the nurse reinforce with the client? (Select all that apply.) A. Use carbohydrate counting. B. Limit protein intake. C. Limit alcohol intake. D. Use a diabetes exchange list. E. Choose foods low in fat content.

Correct Answers: A, C, D, E Rationale: A glycosolated hemoglobin A1C level of 9.5% corresponds to an average blood glucose level of 226 mg/dL. The American Diabetic Association recommends an A1C of 7% or less for clients with diabetes. The goals for nutrition therapy in type 2 diabetes emphasize achieving glucose, lipid and blood pressure control. Because overweight and obesity are associated with increased insulin resistance, the client should maintain a nutritionally adequate meal plan with appropriate serving sizes. Carbohydrate counting is a recommended meal planning technique to help track the amount of carbohydrates eaten and keep carbohydrates within a healthy range. A diabetes exchange list is another method to track carbohydrates and allows the client to form a list of exchanges for each meal and snack. Alcohol should be consumed in moderation because it prevents gluconeogenesis and can make managing the diabetes more difficult. The recommended daily protein intake for diabetics is the same as for non-diabetics.

The nurse observes a client using crutches. Which of the following actions by the client would require the nurse to intervene? (Select all that apply.) A. The client is resting their axillae or armpits on top of the crutches. B. The client has a spare pair of crutches and rubber tips. C. The handgrips of the crutches are even with the client's hips. D. While using a three-point gait, the client is bearing weight on both legs. E. The client is using crutches that have a broken rubber tip.

Correct Answers: A, D, E Rationale: When clients use crutches, their hands should rest on the handgrips of the crutches. The client's weight should not be resting on their axillae, as this could lead to damage of the axillary nerve. Clients should check the integrity of their crutches, including the rubber tips. The crutches should be in good working order and not broken or worn down. Clients should have a spare pair of crutches, including rubber tips. A three-point crutch gait is used for people who only have one weight-bearing leg.

The parent of a 5-year-old child is concerned about an outbreak of measles in the community. The nurse understands that additional education about immunizations is needed when the parent makes which of the following statements? (Select all that apply.) A. "We should avoid playing with children with high fevers." B. "My child should have passive immunity from the vaccine I had as a child." C. "My child should receive a second dose of the measles vaccine now." D. "My child is unlikely to get measles because of their first vaccine at age one." E. "If a child develops a rash, the risk of spreading measles is gone."

Correct Answers: B & E Rationale: Measles is a preventable communicable disease that was well controlled in the United States until recently. There have been outbreaks of measles in communities where children did not receive the vaccines. The Centers for Disease Control and Prevention (CDC) recommends immunization at around age one, with a booster between ages four and six. The child should be protected from the disease after the first vaccine. The period of time measles is communicable is from 3 to 5 days before the rash appears until about four days after the rash appears. In the first year of life, the child may have passive immunity from the mother. It is important to avoid being in confined spaces with any individual with a high fever.

A surgical client with acute pain refuses to participate in physical therapy. The client still has pain despite the administration of pain medication. Based on the information provided, which nonpharmacological intervention(s) would be appropriate for the nurse to add to the plan of care? (Select all that apply.) A. Keep the client on strict bedrest until the pain completely resolves. B. Assist the client in meditating before going to physical therapy. C. Ensure the client's room is kept at a comfortable temperature for physical therapy. D. Provide the client with a light back massage before physical therapy. E. Apply ice directly to the surgical incision 30 minutes before therapy.

Correct Answers: B, C, D Rationale: Nonpharmacological therapies are essential for pain management. For example, they can minimize the use and duration of use of synthetic medications for pain control, which can minimize medication side effects. Nondrug therapies can increase a client's sense of control and their ability to cope with pain. When using cold therapy, always protect the skin before application of the therapy, and do not apply cold objects or ice to open wounds. Keeping the client's room well-lit, quiet and at a comfortable temperature can also help manage pain. Massage can reduce muscle tension and stress, thus helping reduce pain. Keeping a client on bedrest after surgery is contraindicated because it can lead to complications such as pneumonia, pressure ulcers and deep vein thrombosis. It is also unrealistic for a surgical patient to not have any pain. Relaxation techniques such as music, meditation and deep breathing can help reduce stress and anxiety, alleviate muscle tension and enhance the effectiveness of other pain relief measures.

The nurse is caring for a client with a new sigmoid colostomy. Which statement(s) by the client will require additional teaching by the nurse? (Select all that apply.) A. "A small amount of bleeding might occur when I clean around the stoma." B. "I should only change the pouch when it starts to fall off." C. "I'm sad that I cannot go swimming anymore." D. "The stool consistency should be liquid and green or yellow in color." E. "I plan on going back to work right away." F. "The color of the stoma should be rosy pink to brick red."

Correct Answers: B, C, D ,E Rationale: Colostomies are temporary or permanent surgical openings created in the abdominal wall to allow fecal elimination. The portion of the ostomy that is visible is called the stoma. A sigmoid colostomy is the most common type of ostomy and tends to produce more solid stool than all other colostomies. Normal stool is brown in color. Green or yellow, liquid stool can indicate a gastrointestinal (GI) infection. A small amount of bleeding from the stoma while cleaning is normal due to the vascularity of the bowel. However, a large amount of bleeding from the stoma may indicate a GI bleed or coagulopathy. A viable stoma should be rosy pink to red in color, not pale or dark. A pale pink stoma may indicate anemia (i.e., blood loss), while a dark grey/purple stoma may indicate poor blood flow to the bowel (i.e., ischemia or necrosis). Individuals with a new colostomy should avoid heavy lifting. They may resume normal activities of daily living within 6 to 8 weeks of colostomy formation. Individuals with colostomies can swim as long as their ostomy pouch is intact. A patient with a sigmoid colostomy can use a drainable pouch or closed end pouch. The current recommendations state that drainable pouches should be changed every 4 to 7 days and closed end pouches should be changed daily.

The nurse is collecting data on a client who is complaining of drowsiness and an inability to concentrate. Which statements by the client's spouse indicate the client might be suffering from obstructive sleep apnea? (Select all that apply.) A. "His legs are usually swollen at the end of the day." B. "He seems to snore less when he sleeps in a chair." C. "He stops breathing sometimes at night." D. "He says he feels short of breath when lying flat." E. "He is very irritable and tired, even when he has slept 12 hours the night before." F. "He snores really loud during the night. I have to sleep in the other bedroom." G. "He falls asleep anytime he sits down."

Correct Answers: B, C, E, F, G Rationale: The most common clinical manifestation of obstructive sleep apnea (OSA) is daytime sleepiness and the inability to maintain concentration. Often, the client's family members will state the client snores loudly and stops breathing while sleeping. Swelling in the lower extremities and shortness of breath when lying supine (orthopnea) are related to heart failure, not OSA.

The nurse is caring for a client admitted with a phosphorus level of 1.5 mg/dL. Which statement by the client should alert the nurse to collect further data about possible causes for the phosphate imbalance? (Select all that apply.) A. "I have a history of decreased kidney function." B. "I take a calcium supplement with every meal." C. "I had my parathyroid gland surgically removed." D. "I do not eat any meat or dairy products." E. "I snack on nuts in-between meals."

Correct Answers: B, D Rationale: Hypophosphatemia refers to a below-normal concentration of phosphorus in the ECF (serum phosphate less than 2.5 mg/dL). The most common causes of hypophosphatemia are depletion of phosphorus because of insufficient intestinal absorption, hypercalcemia, transcompartmental shifts and increased renal losses. Lack of parathyroid hormone (PTH) after removal of the parathyroid gland leads to decreased blood levels of calcium (hypocalcemia) and increased levels of blood phosphorus (hyperphosphatemia), not hypophosphatemia. Nuts are high in organic phosphorus and considered good snack foods. Meats and dairy products are high in phosphate and a lack of intake of those foods can lead to a low serum phosphorus level.

A nurse is caring for a client who has reported pain at their surgical site. Which statement(s) suggests the nurse understands the pain phenomenon? (Select all that apply.) A. Pain is an emotional response to tissue inflammation or damage. B. Pain is universal and can be easily treated most of the time. C. Pain exists when and where the client says it exists. D. Clients from Eastern cultures usually require less pain medication. E. Pain can be treated with pharmacologic and/or nonpharmacologic therapies. F. Postoperative pain should only be assessed by the physician.

Correct Answers: C & E Rationale: Assessing/evaluating pain is an important part of the nurse's responsibility in all nursing care circumstances, including postoperative pain. Pain is subjective, highly individualized and sometimes complex to treat. Pain is a physiological process and sensation caused by a specific stimulus that can include inflammation and tissue damage. It is a misconception that clients from Eastern cultures need less pain medication.

The nurse is caring for a client who is receiving bolus enteral tube feedings. Which of the following actions by the nurse demonstrate safe practice for this client? (Select all that apply.) A. Flushing the tube with 30 to 60 mL of water every hour B. Placing the patient in the supine position for 30 minutes after each feeding C. Aspirating and measuring the residual gastric contents before each feeding D. Providing oral hygiene every 48 hours. E. Maintaining the head of the bed at 30 to 45° during feedings F. Connecting the tube to low intermittent wall suction 45 minutes after the feeding. G. Verifying the initial placement of the tube by radiographic assessment

Correct Answers: C, E, G Rationale: Safe care of clients receiving enteral feedings focuses on preventing regurgitation and aspiration. This is done by verifying the initial placement of the tube via radiographic assessment, maintaining the head of bed above 30° during and for 30 minutes following the feeding and ensuring the patient is able to tolerate the volume and speed of the nutrition by measuring residual volumes prior to feeding. Flushing the tube every hour is not indicated and could lead to fluid overload. Placing the client in a supine position is contraindicated after just having received a bolus of tube feeding, because it increases the risk of regurgitation and aspiration. Oral care should be provided regularly and at least every shift. Connecting the tube to suction is incorrect.