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25.A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.) A. Broth B. Grape juice C. Nonfat milk D. Custard E. Lemon gelatin

A,B,E Rationale: Broth is correct. Fat-free broth is an acceptable component of a clear liquid diet. Coffee and tea are also acceptable.Grape juice is correct. Grape juice is an acceptable component of a clear liquid diet, along with apple juice and cranberry juice.Nonfat milk is incorrect. Nonfat milk is an acceptable component of a full liquid diet, not a clear liquid diet.Custard is incorrect. Custard is an acceptable component of a full liquid diet, not a clear liquid diet.Lemon gelatin is correct. Lemon gelatin is an acceptable component of a clear liquid diet, along with sugar, honey, hard candy, and ice pops.

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment Rationale: The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position. Rationale: This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

Weak pulse Rationale:A decreased volume of circulating blood and less pressure within the vessels results in weak peripheral pulses (rated as +1), which can be described as thready.

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

Yogurt Rationale:Yogurt is allowed on a full liquid diet, not a clear liquid diet.

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching?

"I will have him sit in his chair during the feeding." Rationale: The client should be placed in a Fowler's position or in a sitting position in a chair, which is the normal position for eating. This is the position that will prevent aspiration of fluid into the lungs and promote a gravitational flow.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms. Rationale:Asking the client to push with her feet against the nurse's hands is an appropriate method of determining the client's level of physical strength, which is needed for ambulation.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP Rationale:A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted?

Bear down. Rationale:Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood Rationale:A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. The client's BP is 142/88 mm Hg, his body mass index (BMI) is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders?

Cardiovascular disease Rationale: Risk factors for cardiovascular disease include BP elevation, obesity, smoking, and a sedentary lifestyle.

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?

Discard unused formula after 8 hr. Rationale: The nurse should discard unused formula 8 to 12 hr after reconstitution to reduce the risk for bacterial growth.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

Earlobe Rationale: The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Explain to the client what is about to happen. Rationale:Explaining assessment techniques can decrease stress and anxiety. It also increases trust and promotes a therapeutic nurse-client relationship.

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Grape juice Rationale:A clear liquid diet includes foods that are fluids and clear at body and room temperatures. This includes apple and grape juices, broth, black coffee, and plain gelatin.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose. Rationale: The nurse should inhale slowly and evenly through her nose until chest expansion is maximized.

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis Rationale:Kyphosis, a forward, "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine resulting from multiple compression fractures, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging.

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea Rationale:Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?

Perform a bladder scan. Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Places the client's arm above the level of the client's heart Rationale: The partner should place the client's arm at heart level to ensure accurate blood pressure readings.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space Rationale: The left second intercostal space is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in this area.

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

The time span in question is 2.5 hr.120 + 120 + 60 = 300 mL infused.120 mL/hr X 2.5 hr = 300 mL

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

Urinary tract infection Rationale:A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCs, RBCs and bacteria. The urine often has an unpleasant odor.

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop Rationale:An S3 represents a ventricular gallop caused by a rush of blood into a ventricle that is stiff or dilated. This can be a finding of heart failure and hypertension.

A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend?

Walking Rationale: The nurse should recommend low impact exercises, such as yoga or walking, to maintain and increase strength and flexibility.