NU270 Module 7

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 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:

A "Most newborns sleep about 16 hours a day"

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

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.

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 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 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?

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

A 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:

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.

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?

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 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:

A Document the results 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.

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:

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.

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.

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

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:

A Notify the physician

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 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.

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?

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 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:

B 8 inches 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 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

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:

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

B Increased sodium excretion Rationale: A serum potassium level of 5.8 mg/dL is high, indicating potassium retention associated with the use of the potassium-sparing diuretic. When potassium is retained, the kidneys excrete more sodium.

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:

B Injury to the nerves Rationale: When crutches are correctly fitted, the tops are three to four fingerbreadths, or 1 to 2 inches, 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 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?

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 in one of these formulas were administered. If the client is found to be lactose intolerant, the physician should prescribe a lactose-free formula. This will resolve the client's symptoms and promote adequate nutrition for the client

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

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.

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:

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

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

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

B That she should cleanse the perineum from front to back

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:

C 4 inches 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, in a child 2 to 3 inches, and in an infant 1 to 1½ inches.

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?

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 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:

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.

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?

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.

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?

C Chicken breast, broccoli, strawberries, milk

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

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

59. 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?

C 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?

C Eggs Rationale: One large egg provides 66 mg of potassium

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?

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 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.

C Scallops ,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.

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:

C 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:

C This is a normal occurrence as a person gets older

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:

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

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?

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

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:

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 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?

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.

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?

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. The CPM machine is used while the client is in bed.

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

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.

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

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 only 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

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:

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

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:

D 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.

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?

D Having the client assist by using the overhead trapeze

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?

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 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:

D The client administers his own medication by pressing a control button

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

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

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?

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.

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 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 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

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 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.

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 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 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 Prune 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.

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 Rationale: Triamterene is a potassium-sparing 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.

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 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 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 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.

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 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.

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 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.