Nokea
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
- A. Macaroni & cheese
- B. Fresh fruit & whole wheat toast
- C. Rice pudding & ripe bananas
- D. Roast chicken & white rice
Correct Answer: B
Rationale: The correct answer is B: Fresh fruit & whole wheat toast. Fresh fruits are high in fiber, which aids in digestion and helps prevent constipation. Whole wheat toast also contains fiber, promoting regular bowel movements. Macaroni & cheese (A) and rice pudding & ripe bananas (C) are low in fiber and may worsen constipation. Roast chicken & white rice (D) lack sufficient fiber to alleviate constipation.
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A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
- E. Nausea
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (A) and diarrhea (B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nurse is caring for a client who is receiving continuous enteral feedings. What is the highest priority intervention when the nurse suspects aspiration?
- A. Auscultate breath sounds.
- B. Stop the feeding.
- C. Obtain a chest x-ray.
- D. Initiate oxygen therapy.
Correct Answer: B
Rationale: The correct answer is B: Stop the feeding. Aspiration can lead to serious complications such as pneumonia. Stopping the feeding immediately is crucial to prevent further aspiration and minimize harm to the client. Auscultating breath sounds (choice A) is important but should be done after stopping the feeding. Obtaining a chest x-ray (choice C) may be necessary later for further evaluation but is not the highest priority in this situation. Initiating oxygen therapy (choice D) may be needed depending on the client's condition, but it is not the highest priority when aspiration is suspected.
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. "The roommate is up independently"
- B. The client ambulates w/his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain medication 30 min ago
- E. The client is allergic to codeine
Correct Answer: B, C, D
Rationale: Correct Answer: B, C, D
Rationale:
- Option B: The client should not wear slippers over antiembolic stockings as it can increase the risk of slipping or falling.
- Option C: Knowing that the client uses a front-wheeled walker is crucial for safe ambulation post-knee arthroplasty.
- Option D: Advising on the timing of pain medication helps ensure the client is comfortable during ambulation.
Summary:
- Option A is incorrect because the roommate's ambulation status is irrelevant to the client's care.
- Option E is incorrect as the client's allergy to codeine does not directly impact safe ambulation post-knee arthroplasty.