Nokea
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?
- A. Eating yogurt can help decrease gas odor that I have.
- B. I should eliminate pasta from my diet so that I don't have as many loose stools.
- C. My largest meal of the day should be in the evening.
- D. Carbonated beverages can help control odor.
Correct Answer: A
Rationale: The correct answer is A. Yogurt contains probiotics which can help reduce gas and odor in colostomy patients. Choice B is incorrect because pasta is a low-fiber food that can help thicken stools, which may be beneficial for colostomy patients. Choice C is incorrect because it is generally recommended for colostomy patients to have their largest meal earlier in the day to allow for better digestion. Choice D is incorrect because carbonated beverages can actually increase gas production and worsen odor in colostomy patients.
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A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine is the antidote for heparin overdose. It works by neutralizing the anticoagulant effects of heparin. Amicar (Choice B) is used to treat excessive bleeding due to elevated fibrinolytic activity and is not the antidote for heparin overdose. Imferon (Choice C) is an iron supplement and is not indicated for heparin overdose. Diltiazem (Choice D) is a calcium channel blocker used to treat hypertension and angina, not for heparin overdose. Therefore, the correct choice is Protamine (Choice A).
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. Abdominal x-ray
- B. Auscultation
- C. Flushing tube with saline
- D. Aspiration for gastric contents
Correct Answer: D
Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.
The nurse is about to assess a 6-month-old child with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be
- A. Irritable and 'colicky' with no attempts to pull to standing
- B. Alert, laughing, and playing with a rattle, sitting with support
- C. Skin color dusky with poor skin turgor over the abdomen
- D. Pale, thin arms and legs, uninterested in surroundings
Correct Answer: D
Rationale: A baby with nonorganic failure-to-thrive often appears pale, thin, and uninterested in their surroundings. Choice A is incorrect as 'irritable and colicky with no attempts to pull to standing' is more indicative of other conditions like colic. Choice B is incorrect as a baby with nonorganic failure-to-thrive is unlikely to be alert, laughing, and playing, as they would typically present with signs of failure to thrive. Choice C is incorrect as dusky skin color and poor skin turgor are not typical findings in a baby with nonorganic failure-to-thrive.
The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?
- A. I will limit my intake of high-sodium foods.
- B. I will take my medications as prescribed by my healthcare provider.
- C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
- D. I will limit my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 g/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct Answer: D
Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.