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A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
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A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E.
A: Wearing an N95 mask is crucial to prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain infectious particles.
E: Wearing a gown within 3 feet of the client prevents exposure to bodily fluids.
D: Removing the mask after exiting the room increases the risk of contamination.
False options would include not utilizing an N95 mask, not isolating soiled linens, not placing the client in a negative airflow room, and not wearing appropriate PPE when close to the client.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is A: Check the client for injuries. This is the first priority to ensure the client's immediate safety and well-being. By assessing for injuries first, the nurse can determine the severity of the situation and provide appropriate care. Moving hazardous objects (B) can wait until the client's safety is ensured. Notifying the provider (C) can be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
- A. Advocacy ensures clients' safety health and rights
- B. Advocacy ensures that nurses are able to explain their own actions.
- C. Advocacy ensures that nurses follow through on their promises to clients.
- D. Advocacy ensures fairness in client care delivery and use of resources.
Correct Answer: A
Rationale: The correct answer is A because advocacy in nursing involves actively supporting and promoting clients' safety, health, and rights. Advocacy ensures that nurses prioritize the well-being and best interests of their clients, advocating for their needs and empowering them to make informed decisions about their care. The other choices are incorrect because B focuses on self-explanation rather than client-centered advocacy, C is more about accountability than advocacy, and D touches on fairness but does not directly address the core concept of advocacy for clients' safety, health, and rights.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?
- A. Turn the client every 2 hours.
- B. Administer an anti-cholinergic medication.
- C. Hold oral care.
- D. Increase the room's temperature.
Correct Answer: B
Rationale: The correct answer is B: Administer an anti-cholinergic medication. This is because anti-cholinergic medications can help reduce secretions in the airway, thus improving the client's breathing and reducing the noisy respirations. Turning the client every 2 hours (choice A) may provide comfort but does not address the immediate issue of airway secretions. Holding oral care (choice C) is important for overall comfort but does not directly address the client's breathing difficulty. Increasing the room's temperature (choice D) is unlikely to improve the client's respiratory distress and may even make it worse.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
- A. Assist the client into a prone position.
- B. Place a sleeve over the top of each leg with the opening at the knee.
- C. Make sure two fingers can fit under the sleeves.
- D. Set the ankle pressure at 65 mm Hg.
Correct Answer: C
Rationale: The correct answer is C: Make sure two fingers can fit under the sleeves. This action ensures proper fit and compression without causing restriction or compromising circulation. A: Assisting the client into a prone position is not necessary for applying the sleeves. B: Placing the sleeve with the opening at the knee is incorrect as it should be at the top of the leg. D: Setting the ankle pressure at 65 mm Hg is not specified for thigh-length sleeves and may not be appropriate.