Nokea
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.
You may also like to solve these questions
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client?
- A. Tamoxifen
- B. Leuprolide
- C. Finasteride
- D. Cyclophosphamide
Correct Answer: B
Rationale: The correct answer is B: Leuprolide. Leuprolide is a gonadotropin-releasing hormone agonist that suppresses testosterone production, which can help slow the growth of prostate cancer. Tamoxifen (A) is used for breast cancer, Finasteride (C) is used for benign prostatic hyperplasia, and Cyclophosphamide (D) is a chemotherapy drug for various cancers. Therefore, in this case, the most appropriate medication for prostate cancer would be Leuprolide (B).
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
- A. Promote oral hygiene.
- B. Ensure adequate nutrition.
- C. Prevent aspiration.
- D. Relieve the client’s pain.
Correct Answer: C
Rationale: The correct answer is C: Prevent aspiration. This is the priority because with intermaxillary fixation, the client's ability to swallow and protect their airway is compromised. Aspiration can lead to serious complications such as pneumonia. Promoting oral hygiene (A) can be important but not the priority. Ensuring adequate nutrition (B) is important but can be addressed once the risk of aspiration has been minimized. Relieving pain (D) is also important but not the priority over preventing aspiration in this case.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Distorted perceptual field.
- B. Urinary frequency.
- C. Rapid speech.
Correct Answer: C
Rationale: The correct answer is C: Rapid speech. In clients with moderate anxiety, rapid speech is a common finding due to the increased arousal and nervousness associated with anxiety. The individual may talk quickly as a way to cope with their anxiety. Distorted perceptual field (A) is more indicative of severe anxiety or psychosis. Urinary frequency (B) is not a typical finding in moderate anxiety, unless there are underlying medical issues. Rapid speech (C) aligns with the increased arousal and restlessness seen in moderate anxiety.
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?
- A. Turn the client every 4 hours.
- B. Brush the client’s teeth with a suction toothbrush every 12 hours.
- C. Provide humidity by maintaining moisture within the ventilator tubing.
- D. Position the head of the client’s bed in the flat position.
Correct Answer: B
Rationale: The correct answer is B: Brush the client's teeth with a suction toothbrush every 12 hours. This action helps reduce the risk of ventilator-associated pneumonia by preventing the buildup of bacteria in the oral cavity that could be aspirated into the lungs. Ventilator-associated pneumonia is often caused by bacteria from the oral cavity entering the respiratory system. Regular oral care, including brushing the teeth, helps to reduce the bacterial load in the mouth. Turning the client every 4 hours (choice A) helps prevent pressure ulcers but does not directly reduce the risk of ventilator-associated pneumonia. Providing humidity in the ventilator tubing (choice C) is important for maintaining airway moisture but does not specifically target pneumonia prevention. Positioning the head of the client's bed flat (choice D) is important for proper ventilation but does not address oral care and bacterial buildup.