MODULE 7: BASIC CARE & COMFORT
cranberry juice cranberries meats eggs whole-grain breads prunes plums
Foods and fluids that would acidify the urine.
b. consult with the physician before applying the cold compress Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid. For this reason, applying the cold compress to the ankle and elevating the ankle and placing a cold compress under and on top of the ankle are both incorrect. The nurse would not place heat on an injury without a prescription to do so. The nurse would consult with the physician about the prescription for cold application.
A client arrives at the emergency department after sustaining an ankle injury, and the physician prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should: a. Apply the cold compress to the ankle b. Consult with the physician before applying the cold compress c. Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes d. Elevate the ankle and place cold compresses under and on top of the ankle
A simple technique such as muscle relaxation can help ease any existing anxiety and promote sleep. In acupuncture, special needles are inserted into specific points on the body as a means of modifying the perception of pain, normalizing physiological function, or preventing or treating disease. Traditional Chinese medicine is focused on restoring and maintaining a balanced flow of vital energy; interventions in this discipline include acupressure, acupuncture, herbal therapies, diet, meditation, and tai chi and qigong (forms of exercise focused on breathing, visualization, and movement). Herbal therapy involves the use of herbs (plants or plant parts). Some herbs have been found to be safe, but others, even in small amounts, can be toxic, and the nurse would not recommend the use of such a therapy to a client. If the client is taking prescription medications, the client should consult with the healthcare provider regarding the use of herbs, because serious interactions may occur.
A client asks a nurse about complementary and alternative measures to promote sleep. What does the nurse suggest? Herbal therapy Incorrect Acupuncture Muscle relaxation techniques Correct Traditional Chinese medicine
The client's laboratory value reflects hypernatremia; the normal serum sodium range is 135 to 145 mEq/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 a serum sodium level of 151 mEq/L, and the nurse provides instruction regarding foods to avoid. Which of the following menu choices by the client indicates to the nurse that the client needs further instruction? Fish Spinach Rhubarb American cheese Correct
The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter, in essence acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys.
A client has been found to have a bladder infection. Which of the following areas of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? Urethra Nephron Incorrect Glomerulus Ureterovesical junction Correct
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 client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse explains that a cold pack: Reduces muscle tension Dilates the blood vessels Promotes muscle relaxation Reduces blood flow to the extremity Correct
c. tachycardia, d. hypotension & e. mental clouding Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention. The incorrect options are effects opposite those expected with meperidine hydrochloride.
A client is receiving intravenous meperidine hydrochloride (Demerol) as needed for postoperative pain. For which side effects does the nurse assess the client while he is receiving this medication? Select all that apply. a. Polyuria b. Diarrhea c. Tachycardia d. Hypotension e. Mental clouding
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 avoid concentrated sweets.
A client is resuming eating after undergoing partial gastrectomy. What does the nurse tell the client to avoid doing as a means of minimizing the risk of complications? Lying down after eating Incorrect Eating high-protein foods Drinking liquids with meals Correct Eating six small meals per day
A partial bed bath involves bathing only body parts that would give rise to discomfort or odor if they were left unbathed. This includes the axillary and perineal areas and any skin folds. The incorrect options do not completely reflect a partial bed bath.
A client requires a partial bed bath. The nurse, giving instructions to a nursing assistant about the bath, tells the nursing assistant to: Just wash the client's hands and face Provide mouth care and perineal care only Let the client decide what she wants washed Incorrect Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor Correct
b. increased sodium excretion A serum potassium level of 5.8 mg/dL is high, indicating potassium retention associated with the use of the potassium-sparing 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 taking a potassium-sparing diuretic has a serum potassium level of 5.8 mg/dL. The nurse understands that the kidneys will respond with: a. Increased sodium retention b. Increased sodium excretion c. Increased glucose retention d. Increased magnesium excretion
Ingestion of certain foods directly affects urine production and excretion. Coffee, tea, cocoa, and cola, all of which contain caffeine, promote increased urine formation. The incorrect options are not specifically related to the client's complaint.
A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, most appropriately asks the client whether she has been: Regularly exercising Incorrect Experiencing headaches Having heavy menstrual cycles Drinking an excessive amount of coffee Correct
A disulfiram (Antabuse)-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the client not to drink alcohol while taking this medication. The items presented in the remaining options are acceptable for consumption by the client while taking this medication.
A client with a genitourinary tract infection has been prescribed metronidazole (Flagyl) and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states that she must avoid: Alcohol Correct Diet cola Bran flakes Chicken livers
c. rhubarb When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.
A client with a urinary tract infection has been started on nitrofurantoin (Macrodantin), a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to avoid while taking this medication? a. Prunes b. Oranges c. Rhubarb d. Cranberries
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 client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? One low in protein Correct One high in protein Incorrect One with a moderate amount of fat One high in carbohydrates
b. omit 8 oz of skim milk from that meal Yogurt is a milk product. Therefore if the client is going to eat 8 oz 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 client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that after eating the nonfat yogurt she will: a. Not eat ice cream for 2 days b. Omit 8 oz of skim milk from that meal c. Eat only half of an allowed meat product at supper d. Omit salad dressing and butter at lunchtime
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. The CPM machine is used while the client is in bed.
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 of the following actions should the nurse take to protect the knee? Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg Incorrect Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting Correct
b. Loop of Henle 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 has administered a dose of furosemide (Lasix) 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 the: a. Distal tubule b. Loop of Henle c. Collecting duct d. Proximal tubule
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 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. Carrots Tapioca Scallops Correct Broccoli Incorrect Chicken liver Correct
The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed between 6 and 10 inches 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 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: 2 inches to the front and side of the toes Incorrect 8 inches to the front and side of the toes Correct 15 inches to the front and side of the toes 22 inches to the front and side of the toes
Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods.
A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which of the following foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. Eggs Yogurt Correct Parsley Correct Broccoli Cucumbers Incorrect Cranberry juice Correct
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 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 says: "I should bend at the knees to pick things up." "I need to increase the fiber and fluids in my diet." "I can strengthen my back muscles by swimming or walking." Incorrect "I should get out of bed by sitting up straight and swinging my legs over the side of the bed." Correct
One large egg provides 66 mg of potassium. A half-cup of raisins contains 700 mg of potassium. Four ounces of beef contains 420 mg of potassium, and 4 oz of pork contains 525 mg.
A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which of the following menu selections, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction? Pork Beef Eggs Correct Raisins Incorrect
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 caring for a client whose urine output was 25 mL for 2 consecutive hours. Which of the following client-related factors does the nurse recognize as increasing blood flow to the kidneys? Physiological stress Incorrect Release of dopamine Correct Release of norepinephrine Sympathetic nervous system stimulation
Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin, but other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals. Milk is high in vitamins A and D, calcium, and magnesium. Chicken is high in protein. Broccoli is high in calcium and folic acid.
A nurse 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 of the following? Select all that apply. Milk Incorrect Peanuts Correct Chicken Broccoli Asparagus Correct Whole-grain cereals Correct
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 is developing a bowel-training program for a client after a stroke. Select the interventions that are appropriate for inclusion in the plan. Select all that apply. Providing privacy and time for defecation Correct Assisting the client into a sitting position Correct Limiting the amount of fiber in the client's diet Providing a cool drink before defecation time Initiating defecation measures every day at the same time Correct Administering a cathartic suppository a half-hour before defecation time Correct
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 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 evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client is using the cane incorrectly if the client: Holds the cane on the right side Moves the cane when the right leg is moved Correct Leans on the cane when the right leg moves forward Incorrect Keeps the cane 6 inches out to the side of the right foot
The catheter's balloon is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space in which to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could inflict trauma.
A nurse is 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: Immediately inflates the balloon Inserts the catheter 2.5 to 5 cm and inflates the balloon Correct Waits until the urine flow stops and inflates the balloon Inserts the catheter until resistance is met and inflates the balloon
If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, resulting in pain. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space in which to inflate the balloon. The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter or call the physician. Because pain on balloon inflation is not normal, having the client take deep breaths is not the most appropriate action.
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 appropriate nursing action is: Asking the client to take slow, deep breaths Incorrect Removing the catheter and contacting the physician Aspirating the fluid, advancing the catheter farther, and reinflating the balloon Correct Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon
a. plums,b. prunes & f. cranberries Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine. The incorrect options are not food items that will acidify the urine.
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
Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.
A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? "I need to eat foods high in calcium." Incorrect "How I eat can affect my baby's growth." "I need to take vitamins throughout my pregnancy." "My risk for malnourishment is much higher while I'm pregnant." Correct
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, in a child 2 to 3 inches, and in an infant 1 to 1½ inches.
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: 1½ inches 3 inches Incorrect 4 inches Correct 6 inches
The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron is absorbed from eggs and less than 5% from grains and vegetables.
A nurse is providing dietary instructions to a client with tuberculosis. Which of the following foods would the nurse specifically instruct the client to include more of in the daily diet? Rice and fish Incorrect Eggs and bacon Cereals and broccoli Meats and citrus fruits Correct
a. to increase the intake of legumes Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.
A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse tells the client: 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
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 nurse is providing instructions to a client regarding the use of crutches. Which of the following information should the nurse include in the teaching plan? Select all that apply. It is not safe to use someone else's crutches. Correct Rubber crutch tips will not slip, even when wet. The client should use both crutches when navigating stairs. Correct Lean into the crutches as needed to support the body's weight. Incorrect Crutch tips are made of a material that will not wear down.
Ileostomy output is liquid. The addition or elimination of various foods can help thicken this liquid drainage. Bran is high in dietary fiber and will therefore increase the output of liquid stool by hastening its propulsion through the bowel. Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese.
A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which of the following foods that just arrived on the client's meal tray should the nurse discourage the client from eating? Bran Correct Pasta Boiled rice Low-fat cheese Incorrect
Fruits and vegetables tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat (as are avocados), and fish is also naturally lower in fat. Meats and dairy products (e.g., cream cheese) are higher in fat, although modifications can be made to these foods to reduce their fat content.
A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client to avoid? Select all that apply. Avocados Correct Baked tuna Incorrect Green olives Correct Baked potato Fresh cherries Cream cheese Correct
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 provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? Roast turkey with a baked potato Correct Fruit plate with fresh whipped cream Fried chicken with macaroni and cheese Barbecued spare ribs with buttered noodles
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 provides dietary instructions to a client with iron-deficiency anemia. Which of the following foods does the nurse recommend to the client? Select all that apply. Lentils Correct Raisins Correct Pineapple Egg whites Kidney beans Correct Refined white bread Incorrect
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 physician has prescribed a cleansing enema for an adult client. The nurse understands that the maximal volume of fluid that can be administered is: 250 mL 500 mL 750 mL 1000 mL Correct
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 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? Spare ribs, rice, gelatin, tea Pasta, garlic bread, ginger ale Chicken breast, broccoli, strawberries, milk Correct Peanut butter and jelly sandwich, chocolate cake, tea
With approximately 400 mL of urine in the bladder, the client will feel a sensation of bladder fullness. This amount may be altered by habit and may differ slightly from person to person, but the other options are nonetheless incorrect.
An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. How much urine does the nurse estimate that the client has in her bladder if she is feeling a sensation of fullness? 100 mL 250 mL Incorrect 400 mL Correct 800 mL
Avoid fluid intake 2 hours before bedtime to avoid nocturia.
Avoid fluid intake approx.______hours before bedtime to avoid ___________.
a. bran & d. spinach The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, all of which may limit calcium absorption. Good dietary sources of calcium include milk products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.
Calcitriol (Rocaltrol) is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply. a. Bran b. Milk c. Clams d. Spinach e. Orange juice
a. volume of urine output & d. frequency of bowel movements Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other side effects include hypotension and slowed respiration. The incorrect options are not specifically associated with this medication.
Codeine sulfate is prescribed for a client with severe back pain. Which of the following 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
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.
Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain, during the asymptomatic period, a soft diet that is: Low in fat High in fiber Correct Low in residue Incorrect High in carbohydrates
b. Maintain a daily fluid intake of approx. 2500 ml-3000 ml OR "3 L/day"
Maintain a daily fluid intake of approx. ________daily. a. 1500 ml-2500 ml b. 2000 ml-2500 ml c. 2500 ml-3000 ml d. 1200 ml-2000 ml
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 he saw the nursing assistant asking the client to wash his arms. The other options are components of a complete bed bath.
The nurse instructs a nursing assistant that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the nursing assistant: Washing the client's feet Washing the client's chest Incorrect Giving the client a back rub Asking the client to wash his arms Correct
a. spaghetti with fresh tomatoes & c. grilled chicken with turnip greens Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are specifically labeled "low sodium." Saltwater fish and shellfish are higher in sodium.
The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. a. Spaghetti with fresh tomatoes b. Boiled lobster with baked potato c. Grilled chicken with turnip greens d. Instant hot cereal with bacon e. Tomato soup with a ham sandwich
Theophylline is a methylxanthine bronchodilator, and the nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, tea, cola, and chocolate.
The nurse provides instructions to a client who is beginning therapy with theophylline (Theo-24). The nurse recognizes that the client understands the instructions when the client states that he will be sure to limit consumption of: Coffee, cola, and chocolate Correct Oysters, lobster, and shrimp Incorrect Apples, oranges, and pineapple Cottage cheese, cream cheese, and dairy creamers
Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits, including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.
The nurse teaches a client who has begun taking phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine? Select all that apply. Peas Correct Broccoli Correct Potatoes Correct Red wine Avocados Cereal with raisins
Triamterene is a potassium-sparing diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.
Triamterene (Dyrenium) has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client to avoid while taking this medication? Select all that apply. Prunes Correct Apples Peaches Avocados Correct Nectarines Correct Cranberries Incorrect
Older clients have diminished sensitivity to pain and are therefore at great risk for injury from heat or cold applications. Other clients at risk for injury are the very young; those with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the client with diabetes mellitus; and those who are confused or unconscious.
Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? An older client Correct A client with renal calculi A client with osteoporosis Incorrect A client with rheumatoid arthritis
