Nokea
A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
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The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
- A. Maintain the client in a supine position.
- B. Maintain a high-Fowler’s position when the client is in bed.
- C. Elevate the stump on a pillow.
- D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Correct Answer: D
Rationale: Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
- A. Check the circulation of the affected extremity.
- B. Administer additional pain medication.
- C. Reposition the affected extremity.
- D. Document the findings.
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (C) may worsen the condition if circulation is compromised. Documenting the findings (D) is important but not the priority when the client is experiencing severe unrelieved pain.
A nurse is instructing a client who has GERD about positions that can help minimize the effects of reflux during sleep. Which of the following statements indicates to the nurse that the client understands the instructions?
- A. I will lie on my left side to sleep at night.
- B. I will lie on my right side to sleep at night.
- C. I will sleep on my back with my head flat.
- D. I will sleep on my stomach with my head flat.
Correct Answer: A
Rationale: The correct answer is A: "I will lie on my left side to sleep at night." This position helps prevent acid from flowing back into the esophagus due to the anatomical positioning of the stomach and esophagus. When lying on the left side, the stomach is positioned below the esophagus, reducing the likelihood of reflux.
Incorrect choices:
B: Lying on the right side can worsen reflux symptoms as it allows stomach acid to flow back into the esophagus more easily.
C: Sleeping on the back with the head flat may not be as effective in preventing reflux compared to the left side position.
D: Sleeping on the stomach with the head flat can exacerbate reflux symptoms by putting pressure on the stomach and pushing acid back up into the esophagus.
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
- A. 7%
- B. 4%
- C. 1%
- D. 8%
- E. 5%
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn. Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.
A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Prealbumin level.
- B. History of diabetes mellitus.
- C. History of hyperlipidemia.
- D. Wound infection.
- E. Decreased pedal perfusion.
- F. Fasting blood glucose.
Correct Answer: A,B,D,E,F
Rationale: The correct findings that can cause delayed wound healing are A, B, D, E, and F.
A: Prealbumin level reflects protein status, crucial for wound healing.
B: Diabetes mellitus impairs wound healing due to poor circulation and high blood sugar.
D: Wound infection delays healing by increasing inflammation and preventing tissue repair.
E: Decreased pedal perfusion reduces blood flow to the wound site, hindering healing.
F: Fasting blood glucose levels affect the body's ability to heal due to impaired immune function and reduced collagen formation.
Incorrect choices: C - Hyperlipidemia does not directly impact wound healing; G - Insufficient information provided.