NURS 3101 Basic Care and Comfort Practice EAQ

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis?

1 Turkey salad, french fries, sherbet 2 Cottage cheese, mixed fruit salad, milkshake Correct3 Salad, sliced chicken sandwich, gelatin dessert 4 Cheeseburger, tortilla chips, chocolate pudding

A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family?

Answer : Enhances the quality of the client's life Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. Palliative care focuses on reducing symptoms and increasing quality; it does not focus on finding a cure. Nutritional interventions cannot prevent the occurrence of respiratory infections; this requires mobilization of respiratory secretions to prevent stasis. Malabsorption cannot be prevented with teaching; malabsorption may or may not occur depending upon the disease process and functioning of the client's gastrointestinal tract.

Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching?

1 "I must eat foods high in calories." 2 "I should avoid alcoholic beverages." 3 "I will eat more often but in smaller amounts." Answer: 4 "I can eat foods high in fat now that the acute stage is over." The nurse needs to follow up on the client statement that indicates eating foods high in fat can be allowed. A low-fat diet should be followed to avoid diarrhea. All the rest of the client responses are correct and do not require additional teaching. The response to eating foods high in calories is appropriate because additional calories are needed to maintain weight. The response to avoiding alcoholic beverages is appropriate to prevent overstimulation of the pancreas. Small, frequent meals limit stimulation of the pancreas and is appropriate.

Which principle should the nurse consider when assisting a client with crutches to learn the four-point gait?

1 Elbows should be kept in rigid extension. 2 Most of the weight should be supported by axillae. Correct3 The client must be able to bear weight on both legs. 4 The affected extremity should be kept off the ground. In the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. Thus, both legs must be able to bear some weight. Although the arms are extended to allow the hands to bear weight, the elbows are not maintained in this position. Pressure on the axillae may damage nerves in the area. Both extremities must be able to bear weight.

During her first prenatal visit the client reports that her last menstrual period began on April 15. According to Nägele rule, what is the expected date of delivery (EDD)?

1 January 8 Correct 2 January 22 3 February 8 4 February 22 To determine EDD with the use of Nägele rule, subtract 3 months from the date of the last menstrual period and add 7 days. January 8 is 2 weeks too early according to this formula. February 8 is too late. February 22 would be 1 month past the true EDD.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?

1 Pouring warm water over the perineum 2 Ensuring the patency of the catheter Correct3 Removing the catheter within 24 hours 4 Cleaning the catheter insertion site Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.

After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer?

1 Use a transfer board to slide the client from the bed to the chair. 2 Ask the client to put weight equally on both legs and step to the chair. 3 Have several people assist with lifting the client from the bed to the chair. Correct4 Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair. Weight bearing on the unaffected leg will help maintain muscle strength; weight bearing on the affected leg may be limited initially by the primary healthcare provider's prescription or by the client's inability to tolerate weight bearing. Using a transfer board to slide the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription. Asking the client to put weight equally on both legs and step to the chair may be contraindicated; weight bearing on the affected leg without a prescription can disrupt the repair, or the client may not be able to fully bear weight initially because of discomfort. Having several people assist with lifting the client from the bed to the chair does not involve weight bearing; weight bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a primary healthcare provider's prescription.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss? Incorrect1 Measuring the abdominal girth daily 2 Having the child urinate in a bedpan 3 Testing the child's urine for proteinuria Correct4 Weighing the child at the same time each day Comparison of daily weights is the most accurate way to assess fluid retention or loss. Having the child urinate in a bedpan is difficult for a child of this age, and the findings will not be accurate. Measuring the abdominal girth daily is way to assess the degree of ascites; it indirectly measures fluid retention. Assessment of urine for protein gives information about the disease process, but not about the amount of fluid retention.

A patient who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply.

Correct 1 Chemotherapy 2 Repositioning 3 Regular oral care Correct 4 Blood transfusion Correct 5 Radiation therapy Palliative care is a combination of care provided when cure is not possible for a chronic disease. It may include symptom management and comfort measures. Chemotherapy, radiation therapy, and blood transfusions are a part of palliative care meant to alleviate symptoms and promote well-being. These therapies may not be required in a patient who is about to die and is receiving end-of-life care. End-of-life care comprises measures to make the patient as comfortable as possible. It may include measures such as regular oral care and repositioning.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?

Correct1 Apple 2 Orange 3 Tomato 4 Grapefruit Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.

A 10-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage

1 Baked potato, meatloaf, banana, and pretzels 2 Baked ham, bread and butter, peaches, and milk Correct3 Corn on the cob, baked chicken, rice, apple, and milk 4 Hot dog on a bun, potato chips, dill pickle slices, and brownie Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium.

Which is the priority nursing intervention in order to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination?

1 Distracting the client by asking her preference regarding the infant's sex 2 Assisting the practitioner so the client's examination can be completed quickly Correct 3 Explaining the procedure and maintaining eye contact while touching the client gently 4 Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath Explaining the procedure and maintaining eye contact while touching the client gently will help the client relax and will lessen discomfort. Distracting the client by asking her preference regarding the sex of her infant may distract the client; however, this will not produce relaxation. The client may become more anxious if the procedure is hurried. Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath may make the client more anxious; holding the breath causes tightening of the perineum.

A nurse is teaching the parents of an infant with cerebral palsy how to provide optimal care. What should the nurse include in the teaching?

1 Focusing on cognitive rather than motor skills 2 Maintaining immobility of the limbs with splints Correct3 Preserving muscle tone to prevent joint contractures 4 Continuing to offer a special formula to limit gagging

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

1 Ham sandwich with cheese, whole milk, and potato chips Correct2 Penne pasta, spinach, banana, and decaffeinated iced tea 3 Baked lasagna with sausage, salad, and milkshake 4 Hamburger, french fries, and cola A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.

The nurse is providing postoperative care to a client who had surgery in which a hip prosthesis was inserted. An abductor splint is in place. When should the nurse remove the splint?

1 When the client gets up to sit in a chair 2 If the client needs a change of position 3 Once the client's edema and pain have ceased Correct4 During the client's skin care and physical therapy Until the prescription is written to discontinue the abduction splint, it is only removed for mobility such as physical therapy and hygiene; adduction to or beyond the midline is not permitted until allowed by the primary healthcare provider. When the client gets up to sit in a chair, the splint is needed unless the client can be trusted to maintain abduction; flexing the hip with a prosthesis cannot be beyond 60 degrees for up to 10 days; from then on it cannot be beyond 90 degrees until permitted by the primary healthcare provider. If the client needs a change of position, a splint helps to maintain position and keep the hip prosthesis in the hip socket. It is inappropriate to remove the splint once the client's edema and pain have ceased; there are no criteria for discontinuing abduction of the affected extremity.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Correct1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

Which recommendation is most important for the nurse to include in a teaching program for a client who has been placed on a 2-gram sodium diet?

Correct1 Use lemon juice to season meat. 2 Put condiments on food to add flavor. 3 Include canned vegetables in meal preparation. 4 Drink carbonated beverages instead of decaffeinated coffee. Lemon juice adds flavor and is low in sodium. Condiments (e.g., mustard, ketchup) are high in sodium and should be avoided. Canned vegetables contain a large amount of sodium; fresh vegetables should be encouraged. Carbonated beverages generally contain sodium; coffee, even if it is decaffeinated, does not contain sodium.