A client with a colostomy reports gas buildup in the colosto...

A client with a colostomy reports gas buildup in the colostomy bag. The nurse instructs the client that consuming which food items would help prevent this problem? Select all that apply.

A. Yogurt
B. Broccoli
C. Cabbage
D. Crackers
E. Cauliflower
F. Toasted bread

Correct Answer: A,D,F

Rationale: Consumption of yogurt, crackers, and toasted bread can help prevent gas. Gas-forming foods include broccoli, mushrooms, cauliflower, onions, peas, and cabbage. These foods should be avoided by the client with a colostomy until tolerance to them is determined.

The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.

A. Assess pulses and circulation proximal to the fistula.
B. Palpate for thrills and auscultate for a bruit every 4 hours.
C. Check for bleeding and infection at hemodialysis needle insertion sites.
D. Avoid taking blood pressure or performing venipunctures in the extremity.
E. Instruct the client not to carry heavy objects or anything that compresses the extremity.
F. Instruct the client not to sleep in a position that places her or his body weight on top of the extremity.

Correct Answer: B,C,D,E,F

Rationale: An AV fistula is an internal anastomosis of an artery to a vein and is used as an access for hemodialysis. The nurse should implement the following to protect the fistula: palpate for thrills and auscultate for a bruit every 4 hours, check for bleeding and infection at hemodialysis needle insertion sites, avoid taking blood pressures or performing venipunctures in the extremity, instruct the client not to carry heavy objects or anything that compresses the extremity, instruct the client not to sleep in a position that places the body weight on top of the extremity, and the nurse should assess pulses and circulation distal to the fistula.

The nurse is reviewing the antenatal history of several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.

A. Of Asian heritage
B. Two previous miscarriages
C. Prenatal care began during the 3rd trimester
D. History of substance abuse during pregnancy
E. Dietary assessment identified poor eating habits
F. Spontaneous rupture of membranes 24 hours ago

Correct Answer: C,D,E,F

Rationale: Risk factors for neonatal sepsis can arise from maternal, intrapartal, or neonatal conditions. Maternal risk factors before delivery include a history of substance abuse during pregnancy, low socioeconomic status, and poor prenatal care and nutrition. Premature rupture of the membranes or prolonged rupture of membranes greater than 18 hours before birth is also a risk factor for neonatal acquisition of infection. There is no research to associate heritage or previous miscarriages to the development of neonatal sepsis.

A client diagnosed with acute pyelonephritis is scheduled for an intravenous pyelogram this morning. During report the nurse learns that the client vomited several times during the night and continues to report being nauseated. What intervention should the nurse implement to assure the client's safety regarding the scheduled procedure?

A. Cancels the pyelogram
B. Monitors the client closely for any additional vomiting
C. Medicates the client with a standing order for metoclopramide
D. Requests a prescription for a 0.9% saline intravenous infusion

Correct Answer: D

Rationale: The highest priority of the nurse would be to request a prescription for an intravenous infusion. This is needed to replace fluid lost with vomiting, will be necessary for dye injection for the procedure, and will assist with the elimination of the dye after the procedure. The cancelation of the procedure is premature. Neither monitoring nor medicating the patient with an antiemetic will address the fluid loss problem.

The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.

A. Surgery
B. Bladder retraining
C. Scheduled toileting
D. Dietary modifications
E. Pelvic muscle exercises
F. Intermittent catheterization

Correct Answer: B,C,D,E

Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.

A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which intervention should the nurse anticipate to be prescribed for the neonate? Select all that apply.

A. Obtaining serum liver enzymes
B. Administering hepatitis vaccine
C. Supporting breastfeeding every 5 hours
D. Repeating hepatitis B screen in 1 week
E. Administering hepatitis B immune globulin
F. Administering antibiotics while hospitalized

Correct Answer: B,E

Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the neonate should receive the hepatitis vaccine and hepatitis B immune globulin within 12 hours after birth. Obtaining serum liver enzymes, retesting the maternal blood in a week, breastfeeding every 5 hours, and administering antibiotics are inappropriate actions and would not decrease the chance of the neonate contracting the hepatitis B virus.