Module 7

A home care nurse makes a visit to a new mother who delivered a 7-lb girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by telling the mother that:

"Most newborns sleep about 16 hours a day"

A client tells the nurse that he is feeling fatigued because he must get up several times during the night to urinate. The nurse documents that the client is experiencing:

Nocturia

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which of the following foods that just arrived on the client's meal tray should the nurse discourage the client from eating?

Bran

A physician states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through the:

Skin and mechanical ventilator

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should tell the mother that:

The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet?

Vitamin B12

A physician has prescribed a cleansing enema for an adult client. The nurse understands that the maximal volume of fluid that can be administered is:

1000 mL

A client requires a partial bed bath. The nurse, giving instructions to a nursing assistant about the bath, tells the nursing assistant to:

Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

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 client:

Becomes less aware of pain by creating and then concentrating on a mental image

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which of the following foods does the nurse suggest that the client avoid, knowing that it is most likely to taste bitter to the client?

Beef

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that he should follow while the disease is in remission. Which menu selection by the client indicates to the nurse that the client understands the instructions?

Boiled potatoes

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:

Injury to the nerves

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 with the:

Left hand, 6 inches lateral to the left foot

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which of the following foods does the nurse recommend to the client? Select all that apply.

Lentils Raisins Kidney beans

Triamterene (Dyrenium) has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client to avoid while taking this medication? Select all that apply.

Prunes Avocados Nectarines

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply.

A client who has undergone colectomy A client with acute pancreatitis A client who has undergone gastrectomy

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?

2000 to 2500 mL

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which of the following actions should the nurse take to protect the knee?

Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

The nurse instructs a nursing assistant that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the nursing assistant:

Asking the client to wash his arms

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by:

Slightly elevating the foot of the bed

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.

Spaghetti with fresh tomatoes Grilled chicken with turnip greens

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?

Spinach salad, milk, and a banana

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.

Apple juice Chicken broth orange gelatin

A nurse is preparing a list of measures that will help promote sleep. Identify the measures that would be included on the list. Select all that apply.

Adjust the room temperature to a comfortable level. Eliminate lights, noise, and other environmental distractions. Get up at the same time each day and avoid naps during the day

A client with a genitourinary tract infection has been prescribed metronidazole (Flagyl) and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states that she must avoid:

Alcohol

A client has a serum sodium level of 151 mEq/L, and the nurse provides instruction regarding foods to avoid. Which of the following menu choices by the client indicates to the nurse that the client needs further instruction?

American cheese

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application?

An older client

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which of the following parameters does the nurse use to determine the effectiveness of the tube feedings?

Daily weight

A client is resuming eating after undergoing partial gastrectomy. What does the nurse tell the client to avoid doing as a means of minimizing the risk of complications?

Drinking liquids with meals

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which of the following menu selections, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction?

Eggs

A nurse is providing dietary instructions to a client with tuberculosis. Which of the following foods would the nurse specifically instruct the client to include more of in the daily diet?

Meats and citrus fruit

A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that after eating the nonfat yogurt she will:

Omit 8 oz of skim milk from that meal

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client?

One high in protein

A client is receiving intravenous meperidine hydrochloride (Demerol) as needed for postoperative pain. For which side effects does the nurse assess the client while he is receiving this medication? Select all that apply.

Tachycardia Hypotension Mental clouding

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse tells the mother:

That a child cannot control urination until the age of 18 to 24 months

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse tells the client:

To increase the intake of legumes

A client with heart failure and hypertension who has been admitted to the hospital is unable to make her own selections from the menu. Which of the following meals does the nurse select for the client's supper on the day of admission?

Turkey, baked potato, salad with oil and vinegar

Codeine sulfate is prescribed for a client with severe back pain. Which of the following parameters does the nurse monitor while the client is taking this medication? Select all that apply.

Volume of urine output Frequency of bowel movements

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which of the following foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply.

Yogurt Parsley Cranberry juice

A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag?

18 inches

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of:

4 inches

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:

8 inches to the front and side of the toes

The nurse is assigned to care for four clients. Which client does the nurse believe is likely to experience chronic pain?

A client with osteoarthritis

A nurse notes that a client has a diagnosis of acute back pain. The nurse understands that one of the characteristics of acute pain is:

A result of injury

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client to avoid? Select all that apply.

Avocados Green Olives Cream Cheese

A client arrives at the emergency department after sustaining an ankle injury, and the physician prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should:

Consult with the physician before applying the cold compress

Which food should the nurse offer to a client who has been prescribed a full liquid diet?

Cooked custard

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?

Encouraging coughing and deep breathing

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:

Inserts the catheter 2.5 to 5 cm and inflates the balloon

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which of the following? Select all that apply.

Peanuts Asparagus Whole-grain cereals

A nurse is developing a bowel-training program for a client after a stroke. Select the interventions that are appropriate for inclusion in the plan. Select all that apply.

Providing privacy and time for defecation Assisting the client into a sitting position Initiating defecation measures every day at the same time Administering a cathartic suppository a half-hour before defecation time

A nurse administers an oil retention enema to a client. Afterward, the nurse instructs the client to:

Retain the enema for several hours

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. The nurse should tell the client that:

The client administers his own medication by pressing a control button

A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction on observing that:

The client moves the cane and the unaffected side together

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. The nurse should tell the client that:

This is a normal occurrence as a person gets older

A client has been found to have a bladder infection. Which of the following areas of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection?

Ureterovesical junction

A nurse asks a nursing assistant to provide afternoon care to a client. The nurse expects that the nursing assistant will:

Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

A nurse administers a tap water enema (1000 mL) 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:

Document the results

A nurse has administered a dose of furosemide (Lasix) to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on the:

Loop of Henle

A client asks a nurse about complementary and alternative measures to promote sleep. What does the nurse suggest?

Muscle relaxation techniques

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?

My risk for malnourishment is much higher while I'm pregnant

A physician 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. The nurse should:

Notify the physician

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.

Scallops Chicken liver

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. Which of the following client-related factors does the nurse recognize as increasing blood flow to the kidneys?

Release of dopamine

A client with a urinary tract infection has been started on nitrofurantoin (Macrodantin), a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to avoid while taking this medication?

Rhubarb

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 of the following high-risk areas must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?

Right Heel

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions?

Roast turkey with a baked potato

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine sample. What should the nurse tell the client?

That she should cleanse the perineum from front to back

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 of the following actions should the nurse take to stimulate the client's micturition reflex?

Turning on the water in the sink in the client's room and allowing it to run

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 that the client's:

Urine output will be decreased

A nurse is caring for an older adult client. Which of the following occurrences does the nurse recognize as part of the normal aging process?

Urine-concentrating ability increases.

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. How much urine does the nurse estimate that the client has in her bladder if she is feeling a sensation of fullness?

400 mL

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?

Asking the client what she does to prepare for sleep

Calcitriol (Rocaltrol) is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply.

Bran Spinach

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?

Chicken breast, broccoli, strawberries, milk

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. The nurse should:

Clamp the enema bag tubing

The nurse provides instructions to a client who is beginning therapy with theophylline (Theo-24). The nurse recognizes that the client understands the instructions when the client states that he will be sure to limit consumption of:

Coffee, cola, and chocolate

A client with atrial fibrillation has been placed on warfarin sodium (Coumadin). As part of the instructions for the medication, which of the following foods does the nurse tell the client to avoid? Select all that apply.

Lettuce Broccoli Cabbage

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:

Continue the digital removal procedure

A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, most appropriately asks the client whether she has been:

Drinking an excessive amount of coffee

A nursing assistant is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the nursing assistant needs instruction regarding the guidelines for client bathing if she sees the nursing assistant:

Giving the client a complete bed bath

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 states:

"I can pin the pad around the affected area."

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client says:

"I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

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

Left lateral sims

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is:

Aspirating the fluid, advancing the catheter farther, and reinflating the balloon

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client is using the cane incorrectly if the client:

Moves the cane when the right leg is moved

A client who experienced a brain attack (stroke) is experiencing residual dysphagia. Which of the following foods would the nurse remove from the client's meal tray?

Peas

A nurse is providing instructions to a client regarding the use of crutches. Which of the following information should the nurse include in the teaching plan? Select all that apply.

It is not safe to use someone else's crutches. The client should use both crutches when navigating stairs.

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 of the following ingredients is the nurse looking for?

Lactose

The nurse teaches a client who has begun taking phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine? Select all that apply.

Peas Broccoli Potatoes

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 that the client:

Has a diminished capacity to form urine

The nurse is supervising a nursing assistant in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which of the following actions by the nursing assistant while repositioning the client would cause the nurse to intervene?

Having the client assist by using the overhead trapeze

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain, during the asymptomatic period, a soft diet that is:

High in fiber

A client taking a potassium-sparing diuretic has a serum potassium level of 5.8 mg/dL. The nurse understands that the kidneys will respond with:

Increased sodium excretion

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?

Providing cooked fruits such as prunes or apricots

A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse explains that a cold pack:

Reduces blood flow to the extremity

A nurse is monitoring a client's fluid balance. Which of the following 24-hour intake and output totals indicates to the nurse that the client has the proper fluid balance?

Intake 1500 mL, output 1400 mL

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 a:

Pillow to keep the right leg abducted while turning the client

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.

Plums Prunes Cranberries

A client recovering from acute renal failure is being discharged home. The nurse knows that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in:

Potassium