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A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
- A. Light pink urine
- B. Occasional suprapubic cramping
- C. Minimal drainage into the urinary collection bag
- D. Complaints of the feeling of pulling on the urinary catheter
Correct Answer: C
Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.
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A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?
- A. You should increase the fiber in your diet.
- B. You should increase the calories in your diet.
- C. You should decrease the dairy products in your diet.
- D. You should decrease the amount of vitamin D in your diet.
Correct Answer: C
Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?
- A. Boiled rice
- B. Italian bread
- C. Broiled salmon filet
- D. Pickled beets
Correct Answer: D
Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.
A healthcare professional assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct Answer: B
Rationale: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.
A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?
- A. Most of my calories each day should be from fats.
- B. I should eat more calories from complex carbohydrates than anything else.
- C. Simple sugars are needed more than other calorie sources.
- D. Protein should be my main source of calories.
Correct Answer: B
Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.
The client is being taught to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?
- A. Three apricots
- B. Medium banana
- C. Naval orange
- D. Baked potato
Correct Answer: D
Rationale: The correct answer is D. A baked potato is high in potassium and helps prevent digitalis toxicity by maintaining adequate potassium levels. While choices A, B, and C all contain some potassium, a baked potato is a more concentrated source of potassium compared to three apricots, a medium banana, or a naval orange. Therefore, the client should choose a baked potato to better meet the dietary needs for preventing digitalis toxicity.