Basic Care and Comfort

During a postpartum parenting class, a client tells the nurse that to save on the cost of formula, the client has switched her 6-month infant from formula to cow's milk. Which one of the following statements made by the nurse would be the best? A. "Cow's milk can be safely given to an infant older than one year of age." B. "Cow's milk has as lower amounts of protein. The infant will need additional amounts of milk to meet the infant's needs." C. "Powdered formula can be blended with cow's milk to supplement." D. "Cow's milk has higher amounts of iron, which could interfere with blood volume."

A. "Cow's milk can be safely given to an infant older than one year of age."

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned? A. ammonia B. salt water C. vinegar D. bleach

C. vinegar

A client has impaired skin integrity related to compromised circulation. What should the nurse include in the teaching plan regarding nutritional considerations? A. supplementation of diet with vitamins and antioxidants B. elimination of carbohydrates and fats from the diet C. adherence to a diet that helps with weight reduction D. adequate intake of vitamins A and C, protein, and zinc

D. adequate intake of vitamins A and C, protein, and zinc

A client is to receive a glycerin suppository. Which nursing action is appropriate when administering a suppository? A. Applying a lubricant to the suppository B. Instructing the client to bear down during insertion C. Dissolving the suppository in 3 ml of warm water D. Removing the suppository from the refrigerator 30 minutes before insertion

A. Applying a lubricant to the suppository

The parents of a child with diarrhea report to the nurse that they have treated the child with home remedies, including herbal medicine. What is the most important information for the nurse to communicate to the parents regarding the use of home remedies? A. Closely monitor and record the number of stools. B. Share home remedy information with healthcare professionals. C. Read the labels to know what ingredients the child is taking. D. Ensure the home remedy dosage is correct for age.

B. Share home remedy information with healthcare professionals.

A client with right-sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? A. Massage bony prominences. B. Turn the client regularly. C. Perform passive range-of-motion (ROM) exercises. D. Encourage fluid intake.

B. Turn the client regularly.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? A. Turn out the lights in the room. B. Instill artificial tears. C. Alternatively patch one eye every 2 hours. D. Encourage the client to close their eyes.

C. Alternatively patch one eye every 2 hours.

A client with a history of posttraumatic stress is panting and breathing heavily while shouting out some strange words. The nurse reviews the nursing assessment and understands that the client is practicing a form of relaxation called power breathing. The best action for the nurse to take is to: A. allow privacy, but check on the client frequently. B. contact the health care provider for a psychiatric consult. C. arrange for a sitter so the client is not left alone. D. monitor the client for respiratory difficulties.

A. allow privacy, but check on the client frequently.

Which meal would be most appropriate for an adolescent with glomerulonephritis with severe hypertension? A. baked chicken, rice, beans, orange juice B. egg noodles, hamburger, canned peas, milk C. baked ham, baked potato, pear, canned carrots, milk D. hot dog on a bun, corn chips, pickle, cookie, milk

A. baked chicken, rice, beans, orange juice

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated? A. bending over the sink to wash the face B. performing isometric exercises C. walking down the hall unassisted D. lying in bed on the nonoperative side

A. bending over the sink to wash the face

A client has left-sided paralysis. The nurse should document this condition as left-sided A. hemiplegia. B. quadriplegia. C. paraplegia. D. monoplegia.

A. hemiplegia.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? A. Complete and document a Braden skin breakdown risk score for the client. B. Apply a moist-to-moist dressing, being careful to pack just the wound bed. C. Reposition the client off the reddened skin and reassess in a few hours. D. Consult with a wound-ostomy-continence nurse specialist.

C. Reposition the client off the reddened skin and reassess in a few hours.

Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma. How will the nurse determine that the client has been applying the skin barrier correctly? A. There is no odor from the stoma. B. The client only changes the ostomy pouch once a day. C. There is no skin irritation around the stoma. D. The client is adequately hydrated.

C. There is no skin irritation around the stoma.

Which intervention should the nurse suggest to a parent to relieve itching in a child with chicken pox? A. cool compresses moistened with a weak salt solution B. soft towels moistened with hydrogen peroxide C. generous amounts of fine baby powder D. oatmeal preparation baths

D. oatmeal preparation baths

A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used? A. ring or donut B. water bed C. gel flotation pad D. specialty mattress

A. ring or donut

A client with a history of tuberculosis dies. What should the nurse do when caring for the body? A. Prepare to transport the body to an offsite facility for disease validation. B. Contact the local health department to learn how to handle the body. C. Ask the mortician what needs to be done with the body. D. Perform routine postmortem care as identified by the facility.

B. Contact the local health department to learn how to handle the body.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action? A. Apply a warm compress. B. Assess range of motion. C. Elevate the ankle. D. Administer I.V. morphine sulfate as needed.

C. Elevate the ankle.

A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client? A. jojoba B. kava C. ginseng D. melatonin

C. ginseng

An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she makes which statement? A. "I need to reduce my caloric intake to 1,200 calories a day." B. "A regular diet is recommended during pregnancy." C. "I should eat more frequent meals if I get heartburn." D. "I need to consume more fluids and fiber each day."

A. "I need to reduce my caloric intake to 1,200 calories a day."

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client? A. broth, gelatin cubes, and tea B. bananas, rice, applesauce, and toast C. a bland diet tray D. milk, custard, and vanilla ice cream

A. broth, gelatin cubes, and tea

As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? A. "I won't be able to have sexual intercourse until the urinary catheter is removed." B. "I can participate in sexual activity but might not experience orgasm." C. "I should be able to participate in sexual activity, but I'll be infertile." D. "I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay."

B. "I can participate in sexual activity but might not experience orgasm."

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating? A. Have a family member assist with feeding at mealtimes. B. Assist the client in learning to eat with the left hand. C. Continue feeding the client until the hemiplegia resolves. D. Request a diet of thickened liquids that can be taken through a straw.

B. Assist the client in learning to eat with the left hand.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse? A. Retrieve compression stockings from the supply room. B. Check the medical record for a provider's prescription for compression stockings. C. Measure the client for the appropriate sized compression stockings. D. Delegate the placement of compression stockings to the unlicensed assistive personnel (UAP).

B. Check the medical record for a provider's prescription for compression stockings.

The family of a client who died unexpectedly arrives to the care area. In which way should the nurse support the family at this time? Select all that apply. A. Direct the family to the funeral home. B. Expect the family to express grief. C. Serve as an attentive listener. D. Arrange for the family to view the body. E. Provide emotional support.

B. Expect the family to express grief. C. Serve as an attentive listener. D. Arrange for the family to view the body. E. Provide emotional support.

Which nursing intervention is essential while caring for an infant with cleft lip or palate? A. Cradle the infant horizontally while feeding. B. Involve the parents in feeding as soon as possible. C. Choose a regular nursery nipple for feedings. D. Avoid encouraging breastfeeding.

B. Involve the parents in feeding as soon as possible.

A 10-year-old male is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain? A. Perform a head-to-toe assessment. B. Obtain vital signs with a pain score. C. Administer 1 mg morphine as prescribed. D. Change the child's position in bed.

B. Obtain vital signs with a pain score.

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: A. explain alternatives to food such as intravenous fluids that can provide nutrition during hospitalization. B. discuss the situation and possible courses of action with the dietitian and the client. C. teach the client that it is important to eat the food served. D. encourage the client's family to bring food for the client because of the special circumstances.

B. discuss the situation and possible courses of action with the dietitian and the client.

Two days after a herniorrhaphy, the client reports that his scrotum is swollen and painful. To promote comfort, the nurse should instruct the client to: A. lie on his side and place a pillow between his legs. B. elevate the scrotum and place ice bags on the area intermittently. C. wear a truss to support the scrotum. D. apply a snug binder to his abdomen.

B. elevate the scrotum and place ice bags on the area intermittently.

A client is ordered continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. The nurse then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow? A. counter-balancing the I.V. pole B. evaluating patency of the drainage lumen C. attaching the infusion set to an infusion pump D. collecting a urine specimen before beginning irrigation

B. evaluating patency of the drainage lumen

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position? A. supine B. left lateral C. right lateral D. semi-fowler's

B. left lateral

A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? A. trying to persuade the client to eat and thus restore nutritional balance B. providing one-on-one supervision during meals and for 1 hour afterward C. giving the client as much time to eat as desired D. letting the client eat with other clients to create a normal mealtime atmosphere

B. providing one-on-one supervision during meals and for 1 hour afterward

A client is resting in bed. The nurse visits the client to reassess the client's pain. The nurse notices that a visitor is in the room and is touching the client in various places on the client's body. The nurse understands that this type of practice is called: A. yoga B. therapeutic touch C. traditional Chinese medicine D. herbal medicine

B. therapeutic touch

The nurse is assessing the pain level in a client who typically gives a stoic response to describing the pain. Which comment from this client is expected? A. "I can't go on in pain like this any longer." B. "This pain is killing me." C. "Enduring pain is a part of God's will." D. "I've got to see a health care provider (HCP) right away."

C. "Enduring pain is a part of God's will."

The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue? A. "I spend one weekend day a week resting in bed while my husband cares for the children." B. "I get up early in the morning and get all my household chores completed before my children wake up." C. "I sleep for 8 to 10 hours every night so that I'll have the energy to care for my children during the day." D. "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

D. "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? A. "Children don't experience as much pain after surgery as adults." B. "A child who resumes usual play is not experiencing pain." C. "The child's activity level is the best indicator of pain." D. "Some children distract themselves with play while in pain."

D. "Some children distract themselves with play while in pain."

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse? A. Reapply the stockings and make a referral to the skin care team. B. Apply antibiotic ointment to the blister and reapply the stockings. C. Cover the blister with a sterile dressing and reapply the stockings. D. Discontinue the graduated compression stockings and notify the healthcare provider.

D. Discontinue the graduated compression stockings and notify the healthcare provider.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention? A. Provide oral hygiene after eating. B. Refrain from serving snacks as requested. C. Encourage the child to eat all of the meal to get adequate nutrition. D. Have the dietician meet with the child and family to provide foods the child will eat.

D. Have the dietician meet with the child and family to provide foods the child will eat.

The nurse is providing dietary teaching for a client with diabetes. Which statement about the diet would be accurate? A. It is based on nutritional requirements that are the same for all clients. B. It does not include processed foods because they have too many variables. C. It is rigidly controlled to avoid similar diabetic emergencies. D. It is planned around a wide variety of commonly available foods.

D. It is planned around a wide variety of commonly available foods.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse? A. Delegate the placement to the unlicensed assistive personnel. B. Massage the client's legs. C. Ask the client to use the restroom. D. Measure the client's legs.

D. Measure the client's legs.

A client on heparin for a deep vein thrombosis reports an aching pain in the back and finds it difficult to get comfortable when lying in that position. The client refuses to take any medications for pain. What actions would the nurse take to alleviate the back pain? A. Reinforce the importance of changing positions and the possibility of pressure ulcer formation. B. Suggest alternating side-lying positions to lessen the back pain. C. Encourage the client to take the medications to provide optimal rest. D. Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain.

D. Provide lumbar support when in the supine position, offer a back rub, and check the possibility of heat treatments to relieve the pain.

A nurse is taking an admission history, including a medication list, from a client. The listing of which herbal medication would prompt the nurse to ask the client more questions regarding any history of depressive symptoms? A. ephedra B. echinacea C. ginkgo biloba D. St. John's wort

D. St. John's wort

A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. What is the nurse's best response? A. "Let us try this until you can have acupuncture." B. "Acupuncture is still very experimental." C. "I can give you injections if that's what you like." D. "There are very good medications available."

A. "Let us try this until you can have acupuncture."

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences? A. Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." B. "Remember to use a regular tone of voice when you help your spouse speak so your spouse can clearly understand the answers." C. "I am wondering if you are concerned about your spouse's cognitive ability, as you seem to frequently speak for your spouse." D. "Today I noticed that you are speaking for your spouse, and it would be helpful to have practice conversations with your spouse."

A. Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse."

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response? A. Ask the parent for more information about the infant's sleep patterns. B. Reassure the parent that each infant's sleep needs are individual. C. Inform the parent that the infant's growth and development are age-appropriate, so sleep isn't a concern. D. Instruct the parent to decrease the infant's daytime sleep to increase nighttime sleep.

A. Ask the parent for more information about the infant's sleep patterns.

A client has a fiberglass cast on the right arm which was placed after internal fixation 1 week ago. The nurse notes a warm area on the cast. What priority action should the nurse take? A. Assess client's temperature and interview about pain at the site. B. Elevate the casted arm above the level of the heart. C. Ask the client if the cast has gotten wet recently. D. Apply an ice pack to the warm area of the cast.

A. Assess client's temperature and interview about pain at the site.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings? A. Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. B. Premedicate the client with prescribed acetaminophen 500 mg PO 15 minutes prior to application. C. Apply an ice pack to the incision for 15 minutes prior to application. D. Cover the incision with a gauze bandage to provide cushion to the incision.

A. Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application.

During a physical examination, the nurse observes a copper bracelet on a client's wrist. The client states that she is wearing it to treat her arthritis. What should the nurse do? A. Recognize that the client is wearing a protective object she believes prevents illness. B. Encourage the client to continue wearing the copper bracelet because this is a medically supported treatment for arthritis. C. Tell the client that wearing the bracelet is a form of quackery and not to use the bracelet as a treatment. D. Inform the client that this is a not a helpful practice and ask her to remove the bracelet.

A. Recognize that the client is wearing a protective object she believes prevents illness.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied? A. Remove elastic stockings once per day and observe lower extremities. B. Order a second pair of stockings to be rotated each day. C. Elevate the client's legs while out of bed. D. Teach the client isotonic leg exercises.

A. Remove elastic stockings once per day and observe lower extremities.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Use commercial soaps to keep the skin dry. C. Encourage the client to eat a well-balanced diet. D. Perform range-of-motion exercises. E. Tuck bed covers tightly into the foot of the bed.

A. Reposition the client every 2 hours. C. Encourage the client to eat a well-balanced diet. D. Perform range-of-motion exercises.

Which indicates the client with ulcerative colitis has attained an expected outcome of nursing care? A. The client maintains an ideal body weight. B. The client experiences decreased frequency of constipation. C. The client accepts that an ileostomy will be necessary. D. The client verbalizes the importance of restricting fluids.

A. The client maintains an ideal body weight.

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply. A. Weigh the client daily. B. Measure urine specific gravity. C. Place on a calorie-restricted diet. D. Monitor intake and output. E. Restrict fluids.

A. Weigh the client daily. B. Measure urine specific gravity. D. Monitor intake and output.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that A. clients with terminal cancer may develop tolerance to opioids. B. a client who can fall asleep isn't in pain. C. pain medication should be given only when a client requests it. D. only low doses of opioids are safe; higher doses may cause respiratory depression.

A. clients with terminal cancer may develop tolerance to opioids.

A client receiving radiation therapy has fatigue. What should the nurse include in the teaching plan? A. conserve energy by prioritizing activities B. increase fluid intake C. limit dietary intake of high-fiber foods D. minimize naps or periods of rest during the day

A. conserve energy by prioritizing activities

A client asks about complementary therapies for relief of discomfort related to pregnancy. Which comfort measure mentioned by the client indicates a need for further teaching? A. herbal remedies B. medication C. music therapy D. acupuncture

A. herbal remedies

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? A. metabolic alkalosis B. respiratory acidosis C. hypercalcemia D. metabolic acidosis

A. metabolic alkalosis

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to: A. offer finger foods and sandwiches. B. let the client choose some favorite foods. C. provide large, attractive meals. D. provide a stimulating mealtime environment.

A. offer finger foods and sandwiches.

A nurse is caring for a 16-year-old pregnant adolescent. The client is taking an iron supplement. What should this client drink to increase the absorption of iron? A. a glass of milk B. a glass of orange juice C. a liquid antacid D. a cup of hot tea

B. a glass of orange juice

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. A. oatmeal B. apple juice C. cheese D. bacon E. soft drinks F. pepperoni pizza

C. cheese D. bacon E. soft drinks F. pepperoni pizza

A client with chronic pain comes to the clinic for an evaluation. During the visit, the client asks the nurse about possibly using acupuncture for pain relief. Which response by the nurse would be most appropriate? A. "Acupuncture is helpful for acute pain but not chronic pain." B. "You need to get your body into different positions which could increase your pain." C. "Restoring the energy balance in your body could help with pain relief." D. "This type of treatment is not effective in relieving pain."

C. "Restoring the energy balance in your body could help with pain relief."

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device? A. "The splint permits free range of motion of the body area." B. "The splint supports the spine while you are in traction." C. "The splint immobilizes the body part in a functional position." D. "The splint will not be removed for several weeks."

C. "The splint immobilizes the body part in a functional position."

After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema? A. Use a bedside humidifier while sleeping. B. Use corticosteroid nasal spray as needed to control symptoms. C. Apply cold compresses to the area. D. Take analgesics every 4 hours around the clock.

C. Apply cold compresses to the area.

Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? A. Tell the client that a nurse will bring the hearing aid to the postanesthesia care unit as soon as the client wakes up. B. Explain to the client that the premedication that will cause sleepiness and it will not be necessary to hear anything. C. Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery. D. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.

C. Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery.

The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person? A. Ask the facility chaplain to talk with the roommate. B. Permit the roommate to cry alone. C. Console the roommate as grieving begins. D. Change the roommate's assigned room.

C. Console the roommate as grieving begins.

The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? A. Instruct the client to put the head between the knees. B. Give the client a low concentration of oxygen by nasal cannula. C. Have the client breathe into a paper bag. D. Tell the client to take several deep, slow breaths and exhale normally.

C. Have the client breathe into a paper bag.

The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which plan would be best? A. Allow the client to enter the unit kitchen for extra food as necessary. B. Serve the client food in small, attractively arranged portions. C. Serve foods that the client can carry with her. D. Allow the client to send out for favorite foods.

C. Serve foods that the client can carry with her.

The nurse is teaching the caregiver of an older adult client about urinary incontinence. What statement should the nurse make to the caregiver about urinary incontinence in the older adult? A. Urinary incontinence should be accepted as a relatively normal part of aging. B. Among older adults, urinary incontinence is most often a sign of depression. C. Urinary incontinence has many causes and can often be improved with intervention. D. Being incontinent can increase the client's risk for dehydration and confusion.

C. Urinary incontinence has many causes and can often be improved with intervention.

During the first few weeks after a cholecystectomy, the client should follow a diet that includes: A. ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered. B. at least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing. C. a limited intake of fat distributed throughout the day so that there is not an excessive amount in the intestine at any one time. D. a decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine.

C. a limited intake of fat distributed throughout the day so that there is not an excessive amount in the intestine at any one time.

The nurse assesses an infant's urine output and bowel movements. What guideline does the nurse use when determining the appropriate number of wet diapers and stools for an infant at 24 hours of age? A. at least six wet diapers and three stools that are green to yellow B. at least two wet diapers and one to three dark green stools C. at least six wet diapers and one to three black to dark green stools D. at least four wet diapers and at least one dark and sticky stool

C. at least six wet diapers and one to three black to dark green stools

The client has had a myocardial infarction, and the nurse has instructed the client to prevent Valsalva's maneuver. The nurse determines the client is following the instructions when the client: A. clenches the teeth while moving in bed. B. assumes a side-lying position. C. avoids holding the breath during activity. D. drinks fluids through a straw.

C. avoids holding the breath during activity.

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: A. intermittent inflow and continuous outflow of irrigation solution. B. continuous inflow and intermittent outflow of irrigation solution. C. continuous inflow and outflow of irrigation solution. D. intermittent flow of irrigation solution and prevention of hemorrhage.

C. continuous inflow and outflow of irrigation solution.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? A. intermittent epigastric tenderness B. a passage of flatus pre- and postfeeding C. formula in the client's mouth during the feeding, and increased cough D. inability of the client to receive a rapid flow of the feeding

C. formula in the client's mouth during the feeding, and increased cough

The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication? A. oversedation B. hypertensive crisis C. prolonged bleeding D. medication interactions

C. prolonged bleeding

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: A. functional incontinence. B. total incontinence. C. stress incontinence. D. reflex incontinence.

C. stress incontinence.

A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger cookies to help control the nausea. What should the nurse tell the parents? A. "I will need to get a prescription." B. "We discourage the use of home remedies in children." C. "Your child needs medication for the vomiting." D. "You can try them and see how he does."

D. "You can try them and see how he does."

The nurse walks into a client's room to administer the 0900 medications and notices that the client is in an awkward position in bed. What should the nurse do first? A. Ask the client to state his or her name. B. Give the client the medications. C. Check the client's name band. D. Straighten the client's pillow behind the back.

D. Straighten the client's pillow behind the back.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? A. The student nurse disconnects the suction tubing from the NG tube. B. The student nurse puts on clean gloves instead of sterile gloves. C. The student nurse allows the fluid in the syringe to flow by gravity into the NG tube. D. The student nurse irrigates the NG tube through the blue air vent port.

D. The student nurse irrigates the NG tube through the blue air vent port.

The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? A. peanuts B. yogurt C. an orange D. a gelatin dessert

D. a gelatin dessert

A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of A. meditation B. aromatherapy C. biofeedback D. acupressure

D. acupressure

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care? A. devising a bathing and dressing schedule for each morning B. bathing and dressing the client each morning until the client is willing to perform self-care independently C. drawing up a schedule and making certain that it is adhered to D. assisting the client with bathing and dressing by giving clear, simple directions

D. assisting the client with bathing and dressing by giving clear, simple directions

As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first? A. determining whether the client is worried about something B. recommending warm milk or a warm shower at bedtime C. finding out whether the client is taking medication that may impede sleep D. gathering more information about the client's sleep problem

D. gathering more information about the client's sleep problem

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will: A. learn to self-administer enteral feedings every 4 hours. B. regain any weight lost within 4 weeks of the surgical procedure. C. eat three full meals a day without experiencing gastric complications. D. maintain adequate nutrition through oral or parenteral feedings.

D. maintain adequate nutrition through oral or parenteral feedings.

The nurse teaches a pregnant client about the need to take supplemental vitamins with iron during her pregnancy. The nurse should instruct the client to take the iron with which liquid to promote maximum absorption? A. hot chocolate B. tea C. milk D. orange juice

D. orange juice