Nokea
A client with a hiatal hernia asks the nurse about fluids that are safe to drink and that will not irritate the gastric mucosa. What fluid should the nurse tell the client to drink?
- A. Apple juice
- B. Orange juice
- C. Tomato juice
- D. Grapefruit juice
Correct Answer: A
Rationale: Substances that are irritating to the client with hiatal hernia include tomato products and citrus fruits, which should be avoided. Because caffeine stimulates gastric acid secretion, beverages that contain caffeine, such as coffee, tea, cola, and cocoa, are also eliminated from the diet.
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Which of the following conditions may warrant a serum creatinine level?
- A. Rhabdomyolysis
- B. Digitalis toxicity
- C. Glomerulonephritis
- D. All answers are correct
Correct Answer: D
Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
- A. I need to change positions slowly.
- B. I need to monitor my blood pressure every week.
- C. I need to use salt moderately in cooking and on foods.
- D. I need to report signs and symptoms of infection to my doctor.
Correct Answer: D
Rationale: Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Client education includes changing positions slowly to avoid orthostatic hypotension, monitoring blood pressure regularly, and using salt moderately as part of a heart-healthy diet. However, reporting signs and symptoms of infection is not directly related to benazepril use, as infections are not a common side effect. The client may need further teaching to clarify the specific side effects to monitor, such as cough, swelling, or signs of hyperkalemia.
A 28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce?
- A. The Apgar score is 11.
- B. The Apgar score is 9.
- C. The Apgar score is 6.
- D. The Apgar score is 4.
Correct Answer: B
Rationale: The Apgar score assesses appearance, pulse, grimace, activity, and respiration, with a maximum of 10. Bluish hands indicate acrocyanosis, common in newborns, deducting 1 point from appearance, resulting in a score of 9 if other parameters are normal. Option A is impossible, and C and D are too low for a healthy baby.
A client is diagnosed with organic erectile dysfunction and the nurse is collecting subjective data from the client. After the assessment, the nurse explains to the client that which are causes of this disorder?
- A. Stress
- B. Depression
- C. Hypertension
- D. Vascular disease
- E. Diabetes mellitus
- F. Alcohol consumption
Correct Answer: C,D,E,F
Rationale: Erectile dysfunction is the inability to achieve or maintain an erection for sexual intercourse. Organic erectile dysfunction is a gradual deterioration of function; the man first notices diminishing firmness and a decrease in frequency of erections. Causes include inflammation of the prostate, urethra, or seminal vesicles; surgical procedures such as prostatectomy; pelvic fractures or lumbosacral injuries; vascular diseases, including hypertension; chronic neurological conditions such as Parkinson's disease or multiple sclerosis; endocrine disorders such as diabetes mellitus or thyroid disorders; smoking and alcohol consumption; drugs; and poor overall health. Functional (not organic) erectile dysfunction usually has a psychological cause.
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
- A. Cleanse the perineal area with soap and water once a day.
- B. Keep the drainage bag lower than the level of the bladder.
- C. Limit fluid intake so that the bag will not become full so quickly.
- D. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.