Nokea
A client experiencing calcium oxalate renal calculi is told to limit dietary intake of oxalate. The nurse is confident that the teaching has been effective when the client includes which items on a list of foods high in oxalate? Select all that apply.
- A. Beets
- B. Spinach
- C. Rhubarb
- D. Black tea
- E. Cantaloupe
- F. Watermelon
Correct Answer: A,B,C,D
Rationale: Food items that are high in oxalate include beets, spinach, rhubarb, black tea, Swiss chard, cocoa, wheat germ, cashews, almonds, pecans, peanuts, okra, chocolate, and lime peel.
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The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
- A. Minimize the force and friction applied to the skin.
- B. Massage vigorously over bony prominences twice daily.
- C. Perform a systematic skin inspection at least once a day.
- D. Cleanse the skin at the time of soiling and at routine intervals.
- E. Use pillows to keep the knees and other bony prominences from direct contact with one another.
- F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
Correct Answer: A,C,D,E
Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted?
- A. Breast engorgement
- B. Elevated white blood cell count
- C. Lochia rubra on the second day postpartum
- D. Fever over 38°C (100.4°F), beginning 2 days postpartum
Correct Answer: D
Rationale: Endometritis is a common cause of postpartum infection. The presence of fever of 38°C (100.4°F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated; thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal finding.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.