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A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
- A. Calcium-rich foods
- B. Canned or frozen vegetables
- C. Processed meat
- D. Raw fruits and vegetables
Correct Answer: D
Rationale: Raw fruits and vegetables may harbor pathogens, increasing infection risk in immunocompromised clients with HIV.
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The nurse is performing fluid resuscitation on a burn client. Which piece of assessment data is the best indicator that it is effective?
- A. Respirations 24, unlabored
- B. Urine output of 30 mL/hr
- C. Capillary refill <4 seconds
- D. Apical pulse of 110/min
Correct Answer: B
Rationale: Urine output of 30-50 mL/hr is the best indicator of adequate fluid resuscitation in burn clients, reflecting sufficient renal perfusion and fluid balance.
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
Lochia serosa usually is evident on days 4 to 10 postpartum. When teaching the client about postpartum care, how should the nurse describe lochia serosa?
- A. Dark red discharge with small clots
- B. Yellowish discharge
- C. Pinkish to brownish discharge
- D. Clear watery discharge
Correct Answer: C
Rationale: Lochia serosa, days 4-10 postpartum, is pinkish to brownish (C) due to decreased blood and increased serous fluid. Dark red (A) is lochia rubra, yellowish (B) or clear (D) are not typical.
The nurse is caring for a client who is having surgery the next morning. The client says, 'I'm really scared about surgery. I've never been put to sleep before and I'm afraid I might not wake up.' Which response by the nurse is the most therapeutic?
- A. Why are you worried about such a minor procedure?
- B. We can call the doctor and cancel the surgery if you would prefer.
- C. It's normal to be afraid of something new like surgery. Tell me how you feel.
- D. Don't worry, you have a really good doctor and he will see to it that nothing goes wrong.
Correct Answer: C
Rationale: Acknowledging fear as normal and inviting the client to express feelings is therapeutic, fostering trust and emotional support.
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.