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A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
- A. smoothie
- B. sliced banana
- C. pancakes
- D. sunny side up (fried) eggs
Correct Answer: D
Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.
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When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Place the client in a side-lying position
- B. Instill 15 mL of irrigation fluid into the catheter with each flush
- C. Subtract the amount of irrigant used from the client's urine output
- D. Perform the irrigation using a 20 mL syringe
Correct Answer: C
Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?
- A. Impaired balance
- B. Hemiplegia
- C. Muscle sprain
- D. Lower extremity paralysis
Correct Answer: A
Rationale: When the cerebellum is damaged, it leads to impaired balance. The cerebellum plays a crucial role in coordinating movements and maintaining balance. Therefore, assessing the patient's balance is essential in determining the extent of cerebellar damage. Options B, C, and D are incorrect because hemiplegia refers to paralysis of one side of the body, muscle sprain is a soft tissue injury, and lower extremity paralysis involves loss of function in the lower limbs. These conditions are not directly associated with damage to the cerebellum.
A client is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Reassure the client that this is an expected response to grief.
- B. Ignore the client's anger and continue with the plan of care.
- C. Tell the client that anger is not going to help his situation.
- D. Encourage the client to express his anger.
Correct Answer: A
Rationale: When a client is expressing anger about a diagnosis, it is essential for the nurse to validate the client's feelings. Choice A is correct because reassuring the client that anger is an expected response to grief acknowledges the client's emotions and encourages expression, fostering a therapeutic relationship. This validation helps the client feel understood and supported during a challenging time. Choice B is incorrect as ignoring the client's anger can lead to feelings of neglect and hinder effective communication, which is crucial for providing holistic care. Choice C is inappropriate because telling the client that anger is not helpful dismisses the client's emotions and can further escalate the situation, potentially damaging the nurse-client relationship. Choice D is not the best option as it does not involve acknowledging the client's feelings or providing support and validation, which are vital in promoting emotional well-being and trust between the client and the nurse.
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
- A. Assessment
- B. Plan of care
- C. Client history
- D. Medication list
Correct Answer: A
Rationale: The correct answer is A: Assessment. When admitting a client, the nurse should document assessment data first. This information is crucial as it provides a baseline for planning care and treatment. By documenting the assessment initially, the nurse can accurately identify the client's needs and prioritize care. Choice B, Plan of care, would be developed based on the assessment findings, so it should come after the initial assessment. Choices C and D, Client history and Medication list, are important but would typically be documented after the assessment to ensure that the most current and relevant information is captured in the client's record.
The client is receiving discharge instructions for warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will have my blood tested regularly to monitor my INR levels.
- C. I will take the medication at the same time every day.
- D. I will use a soft toothbrush to prevent bleeding gums.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin need to be consistent with their vitamin K intake to maintain a balance in blood clotting. Avoiding foods high in vitamin K is essential as they can interfere with the medication's effectiveness. Choices B, C, and D are all correct statements regarding warfarin therapy. Regular blood testing to monitor INR levels ensures the medication is working effectively, taking the medication at the same time daily maintains a consistent level in the bloodstream, and using a soft toothbrush helps prevent gum bleeding due to warfarin's anticoagulant effects.