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A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?
- A. Tuna fish
- B. Clam chowder
- C. Cheese
- D. Chicken
Correct Answer: C
Rationale: Cheese fits a lacto-vegetarian diet, which includes dairy but excludes meat and fish.
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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Tell the client that it is safe to touch her ostomy.
- B. Request that someone from the client's family participate in the care.
- C. Ask the client to explain her feelings.
- D. Explain why her participation is important.
Correct Answer: C
Rationale: Exploring feelings helps address emotional barriers to self-care.
A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?
- A. I'll keep the height of my walker adjusted so lean slightly forward
- B. I'll slide the walker and move it about a foot in front of me
- C. I'll move the walker and my stronger leg ahead at the same time
- D. I'll keep my elbows slightly bent when I grasp the walker
Correct Answer: D
Rationale: Slightly bent elbows ensure proper posture and control with a walker.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. His partner has been visiting.
- B. He is voiding adequately.
- C. He is allergic to sulfa.
- D. He appears anxious about the transfer.
Correct Answer: C
Rationale: Allergies (sulfa) are critical clinical data for safe care on the new unit.