HESI/Saunders Module 7: Basic Care and Comfort

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through which routes? a. Wound drain and skin b. Skin and mechanical ventilator c. Nasogastric tube and wound drain d. Foley catheter and nasogastric tube

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

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee? a. Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg b. Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting c. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. d. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

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

A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? a. Fats b. Vitamins c. Potassium d. Carbohydrates

c. Potassium Rationale: Most excretion of potassium and control of potassium balance is carried out by the kidneys. In the client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis. Vitamins, carbohydrates, and fats are not normally restricted in the client with AKI.

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction? a. Fish b. Spinach c. Rhubarb d. American cheese

d. American cheese Rationale: The client's laboratory value reflects hypernatremia; the normal serum sodium range is 135 to 145 mEq/L (135-145 mmol/L). On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods from animal sources, which contain physiological saline (e.g., cheese, highly processed meats), and other foods that have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus.

A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond to this via which physiological action? a. Increased sodium retention b. Increased sodium excretion c. Increased glucose retention d. Increased magnesium excretion

b. Increased sodium excretion Rationale: A serum potassium level of 5.8 mEq/L (5.8 mmol/L) is high, indicating potassium retention associated with the use of the potassium-retaining diuretic. When potassium is retained, the kidneys excrete more sodium. The other options do not correctly reflect the relationship between these two electrolytes.

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? a. Chicken, potatoes, and cranberries b. Spinach salad, milk, and a banana c. Peanut butter sandwich, milk, and prunes d. Linguini with shrimp, tossed salad, and a plum

b. Spinach salad, milk, and a banana Rationale: In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The incorrect options represent components of an acid ash diet.

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions? a. Milk b. Cabbage c. Boiled potatoes d. Coffee with cream

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

Which food should the nurse offer to a client who has been prescribed a full liquid diet? a. Toast b. Plain bagel c. Cooked custard d. Scrambled eggs

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

A home care nurse makes a visit to a new mother who delivered a 7-lb (3.1 kg) girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother? a. "Most newborns sleep about 16 hours a day" b. "We should probably have the baby checked out by the doctor." c. "If you see any other neurological alterations, call the pediatrician." d. "It's important to wake the baby every hour to provide stimulation."

a. "Most newborns sleep about 16 hours a day" Rationale: Between birth and 3 months, an infant averages 16 hours of sleep a day. Therefore this newborn's sleep pattern is normal. It is not necessary to wake the newborn every hour to provide stimulation.

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectiveness of the tube feedings? a. Daily weight b. Serum protein level c. Calorie count sheets d. Daily intake and output records

a. Daily weight Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is the daily weight. The client should be weighed at the same time (preferably early morning) each day, wearing the same clothes, on the same scale. The incorrect options may be used to assess nutrition and hydration status, but the effectiveness of the diet is measured by whether the client's body weight is maintained.

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action? a. Asking the client to take slow, deep breaths b. Removing the catheter and contacting the health care provider (HCP) c. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon d. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon

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

A client asks a nurse about complementary and alternative measures to promote sleep. What should the nurse suggest? a. Herbal therapy b. Acupuncture c. Muscle relaxation techniques d. Traditional Chinese medicine

c. Muscle relaxation techniques Rationale: 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 nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. a. Carrots b. Tapioca c. Scallops d. Broccoli e. Chicken liver

c. Scallops e. Chicken Liver Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? a. Smoked ham, fresh carrots, boiled potato b. Hot dog in a bun, sauerkraut, baked beans c. Turkey, baked potato, salad with oil and vinegar d. Shrimp, baked potato, salad with blue cheese dressing

c. Turkey, baked potato, salad with oil and vinegar Rationale: Foods that are high in sodium should be limited in the diet of the client with hypertension and heart failure. Foods in the meat group that are higher in sodium include bacon, luncheon meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for hypertensive clients.

A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action? a. Document the results b. Administer a second tap water enema c. Add soap suds to the enema bag and repeat the enema d. Administer a Fleet enema, then a tap water irrigation

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

An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which action? a. Giving the client a complete bed bath b. Pulling the room curtains around the bathing area c. Turning up the thermostat in the client's room for the bath d. Keeping the side rails (per agency policy) up while away from the client

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

A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply. a. It is not safe to use someone else's crutches. b. Rubber crutch tips will not slip, even when wet. c. The client should use both crutches when navigating stairs. d. Lean into the crutches as needed to support the body's weight. e. Crutch tips are made of a material that will not wear down.

a. It is not safe to use someone else's crutches. c. The client should use both crutches when navigating stairs. Rationale: The client should use only crutches that have been measured and set for him. When ascending or descending stairs, the client generally uses a three-phase sequence involving both crutches. Crutch tips should be kept as dry as possible. Water could cause slippage by reducing the friction of the rubber tip against the floor. If the tips get wet, the client should dry them with a cloth or paper towel. The tips should be inspected for wear, and spare crutches and tips should be available. Leaning into the crutches to support the body's weight increases the risk of axillary nerve injury.

A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which way? a. Left hand, 6 inches (15 cm) lateral to the left foot b. Right hand, 6 inches (15 cm) lateral to the right foot. c. Left hand, placing the cane in front of the left foot d. Right hand, placing the cane in front of the right foot

a. Left hand, 6 inches (15 cm) lateral to the left foot Rationale: The client is taught to hold the cane on the side opposite the weakness. This is because, in normal walking, the opposite arm and leg move together (a.k.a. reciprocal motion). The cane also helps support the affected side as it moves forward and helps the client maintain balance. The cane is placed 6 inches (15 cm) lateral to the fifth toe.

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client? Select all that apply. a. Lentils b. Raisins c. Pineapple d. Egg whites e. Kidney beans f. Refined white bread

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

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? Select all that apply. a. Lying down after eating b. Eating high-protein foods c. Drinking liquids with meals d. Eating six small meals per day e. Eating concentrated sweets during the day

a. Lying down after eating b. Eating high-protein foods d. Eating six small meals per day Rationale: The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbohydrates. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.

The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take? a. Notify the HCP b. Continue administering enemas until the fluid returns clear c. Administer a glycerin suppository and then administer one more enema d. Allow the client to rest for 1 hour and then continue with another enema

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

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? a. One low in protein b. One high in fluids c. One high in carbohydrates d. One with a moderate amount of fat

a. One low in protein Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the formation of ammonia. Therefore the client would benefit from a low-protein diet.

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine? Select all that apply. a. Peas b. Broccoli c. Potatoes d. Red wine e. Avocados f. Cereal with raisins

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

A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning? a. Pillow to keep the right leg abducted while turning the client b. Rolled bath blanket to prevent abduction while turning the client c. Trochanter roll to keep the right leg adducted while turning the client d. Rolled bath blanket to prevent external rotation while turning the client

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

A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan? Select all that apply. a. Providing privacy and time for defecation b. Assisting the client into a sitting position c. Limiting the amount of fiber in the client's diet d. Providing a cool drink before defecation time e. Initiating defecation measures every day at the same time f. Administering a cathartic suppository a half-hour before defecation time

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

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? a. To increase the intake of legumes b. That seafood should be included in the diet c. That organ meats should be included in the diet d. To have at least one serving each day of a citrus fruit

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

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication? Select all that apply. a. Volume of urine output b. Strength of peripheral pulses c. Ability to move the extremities d. Frequency of bowel movements e. Color, motion, and sensation of extremities

a. Volume of urine output d. Frequency of bowel movements Rationale: Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client's urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse effects include hypotension and slowed respiration. The incorrect options are not specifically associated with this medication.

A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) 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 take which action? a. Apply the cold compress to the ankle b. Consult with the HCP 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

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

A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action? a. Immediately inflate the balloon b. Insert the catheter 2.5 to 5 cm and inflate the balloon c. Wait until the urine flow stops and inflate the balloon d. Insert the catheter until resistance is met and inflate the balloon

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

A nurse is monitoring a client's fluid balance. Which 24-hour intake and output totals indicates to the nurse that the client has the proper fluid balance? a. Intake 1600 mL, output 800 mL b. Intake 1500 mL, output 1400 mL c. Intake 2400 mL, output 2900 mL d. Intake 3000 mL, output 2400 mL

b. Intake 1500 mL, output 1400 mL Rationale: The client's urine output should be about the same as the intake during the same period. The only option that reflects this balance is intake 1500 mL, output 1400 mL.

A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain? a. It has a prolonged presence b. It is a result of injury c. It lasts longer than 6 months d. It is usually the result of a chronic disorder

b. It is a result of injury Rationale: Acute pain follows acute injury, disease, or surgical intervention and is rapid in onset and variable in intensity (mild to severe). It lasts a brief time, usually less than 6 months. The incorrect options are descriptions of chronic pain.

A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for that may be causing this problem? a. Maltose b. Lactose c. Sucrose d. Fructose

b. Lactose Rationale: Several tube-feeding formulas contain lactose. A client with a history of lactose intolerance would experience the symptoms identified in the question if one of these formulas were administered. If the client is found to be lactose intolerant, the health care provider should prescribe a lactose-free formula. This will resolve the client's symptoms and promote adequate nutrition for the client.

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? a. Flexing the feet against a footboard b. Slightly elevating the foot of the bed c. Keeping the head of the bed elevated 45 degrees d. Placing the bed in reverse Trendelenburg position

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

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine specimen. What should the nurse tell the client? a. That she should douche before collecting the specimen b. That she should cleanse the perineum from front to back c. That she should collect the urine in the cup as soon as the urine flow begins d. That she should collect the specimen at bedtime and bring it to the laboratory the next morning

b. That she should cleanse the perineum from front to back Rationale: As part of correct procedure, the client should cleanse the perineum from front to back, using the antiseptic swabs packaged with the specimen kit. The client should begin the flow of urine, then collect the sample. The specimen should be sent to the laboratory as soon as possible. It should not be allowed to stand, because improper specimen handling could yield inaccurate test results. It is not normal procedure to douche before collecting the specimen.

A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in the plan of care? a. Offering the client a sleeping pill at night b. Providing the client with a snack at bedtime c. Asking the client what is done to prepare for sleep d. Leaving the television in the client's room on at a very low volume

c. Asking the client what is done to prepare for sleep Rationale: Initially the nurse would ask the client what she does to prepare for sleep. Before implementing any intervention, the nurse must assess the client's habits to determine which are beneficial and which might hinder sleep. For this reason, the other options are incorrect. A snack may or may not be helpful to the client. Even at a low volume, the television may constitute a distraction for the client. Medication should be used only as a last measure and requires a prescription.

A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse should take which action? a. Contact the health care provider b. Discontinue the digital removal procedure c. Continue the digital removal procedure d. Wait 1 hour and then continue the digital removal procedure

c. Continue the digital removal procedure Rationale: Excessive rectal manipulation may cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which may result in a reflexive slowing of the heart rate. The nurse would reassess the client's heart rate during the procedure. If the heart rate drops significantly or the cardiac rhythm changes, the nurse must stop the procedure. A change in heart rate from 88 to 82 beats per minute is not significant; therefore the nurse would continue the procedure.

A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse include in the plan? a. Encouraging oral fluid intake b. Maintaining the client in a supine position c. Encouraging coughing and deep breathing d. Administering the morphine sulfate around the clock

c. Encouraging coughing and deep breathing Rationale: Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk for atelectasis and subsequent pneumonia. The client should be encouraged to cough and deep-breathe to prevent these postoperative complications. Keeping the client supine is counterproductive and could lead to atelectasis. Adequate fluid intake helps liquefy secretions, making their expulsion easier, but does not prevent atelectasis unless coughing and deep breathing is also performed. Because the medication is prescribed as needed, it would not be administered around the clock.

A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process? a. Tubular reabsorption increases. b. Urine-concentrating ability increases. c. Glomerular filtration rate (GFR) is diminished. d. Medications are metabolized in larger amounts.

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

A nurse is developing a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should the nurse include in the plan of care to help maintain an appropriate bowel elimination pattern? a. Limiting vegetable intake to one serving per day b. Limiting whole grains to three servings per week c. Providing cooked fruits such as prunes or apricots d. Including spicy foods in the diet to increase peristalsis

c. Providing cooked fruits such as prunes or apricots Rationale: Older clients often experience changes in the gastrointestinal system that result in impairment of digestion and elimination. In addition, peristaltic action declines with age, and esophageal emptying slows. Therefore the client requires a diet containing fiber to provide bulk for fecal material. Although some spicy foods can increase peristalsis, they can also cause indigestion and diarrhea. Vegetables and whole grains are important sources of fiber, and their consumption should not be limited. Cooked fruits such as prunes or apricots are high in fiber.

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

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

A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the clientis receiving this medication? Select all that apply. a. Polyuria b. Diarrhea c. Tachycardia d. Hypotension e. Mental clouding

c. Tachycardia d. Hypotension e. Mental clouding Rationale: Side/adverse 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 nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed? a. The client holds the cane close to the body b. The client holds the cane on the unaffected side c. The client moves the cane and the unaffected side together d. The client uses the cane to support the affected side and to maintain balance

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

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client makes which statement? a. "I should bend at the knees to pick things up." b. "I need to increase the fiber and fluids in my diet." c. "I can strengthen my back muscles by swimming or walking." d. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

d. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed." Rationale: Clients are taught to get out of bed by sliding near the edge of the mattress, then rolling onto one side and pushing up from the bed, using one or both arms. The back is kept straight and the legs are swung over the side. Proper body mechanics includes bending at the knees, not the waist, to lift objects. Increased fluids and fiber in the diet help prevent straining at stool and, in turn, increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening the lower back muscles.

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? a. "I need to eat foods high in calcium." b. "How I eat can affect my baby's growth." c. "I need to take vitamins throughout my pregnancy." d. "My risk for malnourishment is much higher while I'm pregnant."

d. "My risk for malnourishment is much higher while I'm pregnant." Rationale: 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 administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag? a. 4 inches (10 cm) b. 8 inches (20 cm) c. 10 inches (25.5 cm) d. 18 inches (45.5 cm)

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

A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all that apply. a. Exercise just before bedtime. b. Drink a glass of wine at bedtime. c. Drink a cup (236 ml) of black tea before bedtime d. Adjust the room temperature to a comfortable level. e. Eliminate lights, noise, and other environmental distractions. f. Get up at the same time each day and avoid naps during the day.

d. Adjust the room temperature to a comfortable level. e. Eliminate lights, noise, and other environmental distractions. f. Get up at the same time each day and avoid naps during the day. Rationale: A variety of measures may be used to promote and enhance sleep. These measures include avoiding caffeinated beverages (caffeine is a stimulant) for at least 2 hours before bedtime, avoiding alcohol, maintaining a regular exercise schedule but not exercising immediately before bedtime, getting up at the same time each day, avoiding naps during the day, adjusting the room temperature to a comfortable level, and eliminating lights, noise, and other environmental distractions. Alcohol can lighten and fragment sleep. Exercising just before bedtime promotes stimulation and may prevent sleep. Black tea contains caffeine.

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client? a. Urine output will be decreased b. Urine production will be increased c. Serum osmolality will be decreased d. Urine specific gravity will decreased

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

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother? a. That she may start bladder training at any time b. That her child is too young and that she should not yet be worrying about it c. That a child cannot begin to control urination until approximately the age of 24 months d. That bowel training should be started immediately and then begin bladder training in about 1 month

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

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E

b. Vitamin B12 Rationale: The client on a vegan diet does not consume animal products and is therefore at risk for vitamin B12 deficiency. Fruits and vegetables, which are acceptable to the client on a vegan diet, contain vitamins A, C, and E.

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

c. Eggs Rationale: One large egg provides 66 mg of potassium. A half-cup (114 gm) of raisins contains 700 mg of potassium. Four ounces (113 gm) of beef contains 420 mg of potassium, and 4 oz of pork (113 gm) contains 525 mg.

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

c. Rhubarb Rationale: 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 has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse hould provide the clent with which information about a cold pack? a. Reduces muscle tension b. Dilates the blood vessels c. Promotes muscle relaxation d. Reduces blood flow to the extremity

d. Reduces blood flow to the extremity Rationale: The application of cold reduces blood flow through its vasoconstriction action and eases localized pain. Cold also reduces the oxygen need of the tissues and promotes blood coagulation at the site of injury. The incorrect options are the effects of heat application.

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? a. Roast turkey with a baked potato b. Fruit plate with fresh whipped cream c. Fried chicken with macaroni and cheese d. Barbecued spare ribs with buttered noodles

a. Roast turkey with a baked potato Rationale: The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. Therefore the correct answer is roast turkey with a baked potato, which is a meal low in fat.

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

Left-lying Sims position Rationale: When an enema is administered, the client is placed in the left-lying Sims position so that the enema solution may flow by way of gravity in the natural direction of the colon. Although the knee-chest position does provide exposure to the rectal area, the position is uncomfortable and embarrassing for the client. The supine and the prone positions do not provide adequate exposure or promote gravity flow in the natural direction of the colon.

Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply. a. Bran b. Milk c. Clams d. Spinach e. Orange juice

a. Bran d. Spinach Rationale: 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.

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply. a. A client who has undergone colectomy b. A client with acute pancreatitis c. A client who has undergone gastrectomy d. A client with renal insufficiency e. A client with Alzheimer's disease

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

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

a. Spaghetti with fresh tomatoes c. Grilled chicken with turnip greens Rationale: 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.

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position? a. 2 inches (5 cm) to the front and side of the toes b. 8 inches (20 cm) to the front and side of the toes c. 15 inches (38 cm) to the front and side of the toes d. 22 inches (56 cm) to the front and side of the toes.

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

A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. a. Custard b. Apple juice c. Orange juice d. Chicken broth e. Orange gelatin f. Vanilla ice cream

b. Apple juice d. Chicken broth e. Orange gelatin Rationale: A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin, which are relatively transparent. Custard, orange juice, and vanilla ice cream are components of a full liquid diet.

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. a. Lettuce b. Cherries Correct c. Broccoli d. Cabbage e. Potatoes Correct f. Spaghetti Correct

b. Cherries e. Potatoes f. Spaghetti Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as lettuce, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are foods that are low in vitamin K.

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? a. Low in fat b. High in fiber c. Low in residue d. High in carbohydrates

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

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what? a. Holds the cane on the right side b. Moves the cane when the right leg is moved c. Leans on the cane when the right leg moves forward d. Keeps the cane 6 inches (15 cm) out to the side of the right

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

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys? a. Physiological stress b. Release of dopamine c. Release of norepinephrine d. Sympathetic nervous system stimulation

b. Release of dopamine Rationale: Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow. The factors set forth in the other options result in renal vasoconstriction.

A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement? a. "I shouldn't lie on the pad." b. "I'll avoid using the high setting." c. "I can pin the pad around the affected area." d. "I'll need to keep an eye on my skin for redness."

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

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? a. Spare ribs, rice, gelatin, tea b. Pasta, garlic bread, ginger ale c. Chicken breast, broccoli, strawberries, milk d. Peanut butter and jelly sandwich, chocolate cake, tea

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

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? a. She should avoid napping during the day b. The only thing that will help is a sleeping pill c. This is a normal occurrence as a person gets older d. She needs to stay up later at night to prevent these awakenings

c. This is a normal occurrence as a person gets older Rationale: The total amount of sleep a person needs does not change with increasing age. However, the quality of sleep appears to deteriorate for many older adults, giving rise to complaints of feeling less rested. An older adult awakens more often during the night than a younger person does, and it may take an older adult longer to fall asleep. Therefore the other options are incorrect. Additionally, measures other than medication should be implemented to promote rest and sleep.

A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered? a. 250 mL b. 500 mL c. 750 mL d. 1000 mL

d. 1000 mL Rationale: Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through the infusion of a large volume of solution or local irritation of the colon's mucosa. The maximal volume of solution for an adult is 1000 mL.

A client complains of feeling fatigued because of the need to get up several times during the night to urinate. The nurse documents that the client is experiencing which problem? a. Anuria b. Oliguria c. Polyuria d. Nocturia

d. Nocturia Rationale: Nocturia is excessive urination at night. Anuria is the inability to produce urine. Oliguria is a diminished capacity to form urine. Polyuria is excessive urine output.

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information? a. The child should be able to control defecation at the age of 18 months b. The child will let you know when she is ready to begin bowel training c. Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than boys do d. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

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

A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? a. Urethra b. Nephron c. Glomerulus d. Ureterovesical junction

d. Ureterovesical junction Rationale: 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.

The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene? a. Keeping the head of the bed flat b. Placing pillows beneath the full length of the legs c. Using a log-rolling technique for repositioning d. Having the client assist by using the overhead trapeze

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

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? a. Rice and fish b. Eggs and bacon c. Cereals and broccoli d. Meats and citrus fruits

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

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet? a. Alcohol b. Diet cola c. Bran flakes d. Chicken livers

a. Alcohol Rationale: A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the client not to drink alcohol while taking this medication. The items presented in the remaining options are acceptable for consumption by the client while taking this medication.

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray? a. Peas b. Scrambled eggs c. Cheese casserole d. Mashed potatoes

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

A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery. The nurse responds by telling the client that in this technique, the clientwill experience which? a. Become totally unaware of pain b. Ignore the pain by focusing on the alternate activity c. Alter pain perception though the influence of positive suggestion d. Become less aware of pain by creating and then concentrating on a mental image

d. Become less aware of pain by creating and then concentrating on a mental image Rationale: In guided imagery, the client creates a mental image and then concentrates on the image, becoming less aware of pain and other stimuli. Hypnosis can help alter pain perception through the influence of positive suggestion. Certain distraction techniques, such as music, can help a client ignore pain. No alternative or complementary therapy will allow the client to become totally unaware of pain.

A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines which about the client when planning care? a. Is unable to produce urine b. Is voiding large amounts of urine c. Has difficulty with leakage of urine d. Has a diminished capacity to form urine

d. Has a diminished capacity to form urine Rationale: Oliguria, diminished capacity to form urine, is most often the result of a decrease in renal perfusion. Anuria is the inability to produce urine. Polyuria is the voiding of excessively large amounts of urine. Urinary incontinence is the involuntary loss of urine.

A 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, should most appropriately ask the client about which? a. Has she been regularly exercising b. Has she been experiencing headaches c. Has she been having heavy menstrual cycles d. Has she been drinking an excessive amount of coffee

d. Has she been drinking an excessive amount of coffee Rationale: 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 with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client? a. Beef b. Custard c. Potatoes d. Cantaloupe

a. Beef Rationale: Chemotherapy may distort how certain foods taste to the client. Beef and pork are often reported by people undergoing chemotherapy to taste bitter or metallic. The nurse can promote nutrition by helping the client choose alternative sources of protein. The foods set forth in other options are not likely to cause this problem.

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food that just arrived on the client's meal tray should the nurse discourage the client from eating? a. Bran b. Pasta c. Boiled rice d. Low-fat cheese

a. Bran Rationale: 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.

The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the UAP doing which? a. Washing the client's feet b. Washing the client's chest c. Giving the client a back rub d. Asking the client to wash his arms

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

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. a. Plums b. Prunes c. Apples d. Broccoli e. Cabbage f. Cranberries

a. Plums b. Prunes f. Cranberries Rationale: Meats, eggs, whole-grain breads, cranberries, plums, and prunes increase urine acidity. These foods are metabolized into acid end-products that eventually enter the urine. The incorrect options are not food items that will acidify the urine.

A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client? a. Immediately expel the enema b. Retain the enema for several hours c. Expect to defecate within 30 minutes d. Expect to experience cramping induced by the solution

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

The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? a. A client with osteoarthritis b. A client with angina pectoris c. A client who has undergone appendectomy d. A client with a leg fracture who is in skeletal traction

a. A client with osteoarthritis Rationale: Chronic pain is associated with chronic disease. The pain is prolonged, varies in intensity, and lasts longer than 6 months. The incorrect options are clients who are likely to experience acute pain.

A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney? a. Distal tubule b. Loop of Henle c. Collecting duct d. Proximal tubule

b. Loop of Henle Rationale: Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle. Furosemide does not exert an effect on the areas identified in the other options.

A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day? a. 500 to 1000 mL b. 1000 to 1500 mL c. 1500 to 2000 mL d. 2000 to 2500 mL

d. 2000 to 2500 mL Rationale: A client with normal renal function who does not have heart disease or other alterations requiring fluid restriction should drink 2000 to 2500 mL daily.

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. a. Prunes b. Apples c. Peaches d. Avocados e. Nectarines f. Cranberries

b. Apples c. Peaches f. Cranberries Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. a. Avocados b. Baked tuna c. Green olives d. Baked potato e. Fresh cherries f. Cream cheese

b. Baked tuna d. Baked potato e. Fresh cherries Rationale: 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 provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem? a. Skin breakdown b. Injury to the nerves c. An abnormal stance d. A fall and further injury

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

A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz (240 ml) of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt? a. Not eating ice cream for 2 days b. Omitting 8 oz (240 ml) of skim milk from that meal c. Omitting salad dressing and butter at lunchtime d. Eating only half of an allowed meat product at supper

b. Omitting 8 oz (240 ml) of skim milk from that meal Rationale: Yogurt is a milk product. Therefore if the client is going to eat 8 oz (240 ml) of yogurt at a meal, the client should eliminate the milk product from the same meal. Ice cream is not recommended for the diabetic diet because it is high in fat and sugar. Meat is not a milk product, and it is unnecessary to alter the meat allowance at suppertime. Salad dressing and butter are fats.

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods? Select all that apply. a. Milk b. Peanuts c. Chicken d. Broccoli e. Asparagus f. Whole-grain cereals

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

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. a. Eggs b. Yogurt c. Parsley d. Broccoli e. Cucumbers f. Cranberry juice

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

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches? a. 1½ inches (3.8 cm) b. 3 inches (7.5 cm) c. 4 inches (10 cm) d. 6 inches (15 cm)

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

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness? a. 100 mL b. 250 mL c. 400 mL d. 800 mL

c. 400 mL Rationale: 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.

A nurse is caring for a client who has just returned from a cardiac catheterization through the right side of the groin. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action should the nurse take to stimulate the client's micturition reflex? a. Helping the client stand b. Elevating the head of the bed 90 degrees c. Turning on the water in the sink in the client's room and allowing it to run d. Obtaining assistance to ambulate the client to the bathroom in the client's room

c. Turning on the water in the sink in the client's room and allowing it to run Rationale: To stimulate the micturition reflex, the nurse may provide sensory stimuli such as placing the client's hand in a pan of warm water, warming a bedpan if one is needed for use, running water from a faucet and encouraging the client to listen to it, pouring water over the client's perineum, and encouraging fluid intake. The incorrect options are all inappropriate because the client who has just returned from a cardiac catheterization should remain in bed and head elevation should be minimal to prevent the formation of a hematoma at the catheter insertion site.

A nurse asks an unlicensed assistive personnel (UAP) to provide afternoon care to a client. The nurse expects that the UAP will take which action? a. Give the client a complete bed bath b. Ask the client whether he would like to wash his face c. Give the client a back massage and prepare the client for sleep d. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

d. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens Rationale: Afternoon hygiene care includes washing the client's hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens. It does not involve giving a complete bed bath. Giving the client a back massage and preparing the client for sleep are components of evening or hour-before-sleep care. Asking the client whether he would like to wash his face encourages independence but is not one of the components of afternoon care.

The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items? a. Coffee, cola, and chocolate b. Oysters, lobster, and shrimp c. Apples, oranges, and pineapple d. Cottage cheese, cream cheese, and dairy creamers

a. Coffee, cola, and chocolate Rationale: 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 items in the remaining options are acceptable to consume.

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? a. An older client b. A client with renal calculi c. A client with osteoporosis d. A client with rheumatoid arthritis

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

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take? a. Clamp the enema bag tubing b. Remove the enema tube and allow the client to rest c. Stop the instillation and allow the client to expel the solution d. Raise the enema bag to quickly finish instillation of the solution

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

A client requires a partial bed bath. The nurse, giving instructions to an unlicensed assistive personnel (UAP) about the bath, tells the UAP to take which action? a. Just wash the client's hands and face b. Provide mouth care and perineal care only c. Let the client decide what she wants washed d. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

d. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor Rationale: A partial bed bath involves bathing the 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 about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. Which information should the nurse provide to the client? a. The PCA pump eliminates the need for an intravenous (IV) line b. The client will be able to deliver his own dose of medication every 4 hours c. The client's spouse will be able to administer medication for the client d. The client administers his own medication by pressing a control button

d. The client administers his own medication by pressing a control button Rationale: A PCA pump contains a cartridge or syringe that holds the prescribed pain medication. The client pushes a button to administer a small dose of medication within the limitations prescribed by the health care provider. The pump allows the delivery of small doses of medication at short intervals. The medication is administered by way of the IV route. Only the client should administer the medication as he or she needs it.