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A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate?
- A. Eating a diet high in fiber.
- B. Setting a regular time for elimination.
- C. Using an elevated toilet seat.
- D. Limiting fluid intake to 1,000 mL/day.
Correct Answer: D
Rationale: Limiting fluid intake to 1,000 mL/day is inappropriate, as adequate hydration is needed for bowel function. High-fiber diet, regular elimination times, and elevated toilet seats support bowel retraining.
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Which activity increases the risk of renal calculi?
- A. High fluid intake.
- B. Sedentary lifestyle.
- C. Low-sodium diet.
- D. Frequent urination.
Correct Answer: B
Rationale: A sedentary lifestyle promotes urinary stasis, increasing stone risk.
The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply.
- A. Use a conducting agent between the skin and the paddles.
- B. Place the paddles over the client's clothing.
- C. Call 'clear' before discharging the electrical current.
- D. Record the delivered energy and the resulting rhythm.
- E. Exert 5 to 10 lb of pressure on each paddle to ensure good skin contact.
Correct Answer: A,C,D,E
Rationale: Using a conducting agent (A), calling 'clear' (C), recording energy/rhythm (D), and applying pressure (E) ensure safe and effective cardioversion. Paddles over clothing is incorrect.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.
A client who is recovering from hepatitis A has fatigue and malaise. The client asks the nurse, 'When will my strength return?' Which of the following responses by the nurse is most appropriate?
- A. Your fatigue should be gone by now. We will evaluate you for a secondary infection.
- B. Your fatigue is an adverse effect of your drug therapy. It will disappear when your treatment regimen is complete.
- C. It is important for you to increase your activity level. That will help decrease your fatigue.
- D. It is normal for you to feel fatigued. The fatigue should go away in the next 2 to 4 months.
Correct Answer: D
Rationale: Fatigue is common during recovery from hepatitis A and typically resolves in 2-4 months (D). Secondary infection (A) is not indicated. Fatigue is not drug-related (B), and increasing activity prematurely (C) may worsen symptoms.
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has ordered 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client’s laboratory results, noted below. Based on these results, the nurse should:
- A. Assess the client for bleeding.
- B. Administer the medication.
- C. Inform the physician.
- D. Withhold the dose of Lovenox.
Correct Answer: D
Rationale: Based on the laboratory fi ndings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician.