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A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500 mL in the past 6 hr. Which of the following electrolyte imbalances should the nurse monitor the client for?
- A. Decreased potassium level
- B. Increased sodium level
- C. Increased calcium level
- D. Decreased magnesium level
Correct Answer: A
Rationale: The correct answer is A: Decreased potassium level. Postoperative ileus can lead to gastrointestinal fluid losses, causing a decrease in potassium levels due to excessive drainage through the NG tube. Potassium is an important electrolyte for maintaining normal muscle function, including the heart. Monitoring potassium levels is essential to prevent complications such as cardiac arrhythmias.
Incorrect choices:
B: Increased sodium level - Unlikely in this scenario as excessive drainage would lead to fluid and electrolyte loss.
C: Increased calcium level - Unrelated to postoperative ileus and NG tube drainage.
D: Decreased magnesium level - Possible but not as critical as monitoring potassium levels in this situation.
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A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?
- A. Monitor for leg cramps.
- B. Increase sodium intake.
- C. Monitor for headache.
- D. Take the medication at bedtime.
Correct Answer: A
Rationale: Rationale: Correct answer is A. Leg cramps are a common side effect of hydrochlorothiazide due to electrolyte imbalance. Monitoring for leg cramps will help in identifying and managing this side effect promptly. Choices B and D are incorrect as hydrochlorothiazide can lead to electrolyte depletion, so increasing sodium intake is not recommended, and taking the medication at bedtime may increase nighttime urination. Choice C is incorrect as headaches are not a common side effect of hydrochlorothiazide.
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?
- A. A slice of cheese
- B. A small handful of almonds
- C. A baked apple
- D. Carrot sticks with hummus
Correct Answer: A
Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. The client needs further teaching to understand that cheese does not align with their dietary restrictions. The other options (B, C, D) are suitable choices for a low-fat, low-sodium, and low-cholesterol diet. Almonds are a source of healthy fats, a baked apple is low in fat and sodium, and carrot sticks with hummus are low in fat and cholesterol while providing fiber and nutrients. These options align with the client's dietary needs and do not require further teaching.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.
A nurse is preparing a client who has AIDS for discharge. Which of the following statements should the nurse include in the discharge instructions?
- A. Prevent the spread of infection with good household cleaning practices.
- B. Limit handwashing to once a day to avoid skin damage.
- C. Avoid sharing towels with other people in the household.
- D. Do not disinfect surfaces in the home with bleach.
Correct Answer: A
Rationale: The correct answer is A: Prevent the spread of infection with good household cleaning practices. The nurse should include this statement in the discharge instructions because individuals with AIDS have weakened immune systems, making them more susceptible to infections. Good household cleaning practices can help prevent the spread of infections to the client and others.
Incorrect choices:
B: Limit handwashing to once a day to avoid skin damage - This is incorrect as frequent handwashing is crucial to prevent the spread of infections.
C: Avoid sharing towels with other people in the household - This is incorrect as sharing towels can lead to the transmission of infections.
D: Do not disinfect surfaces in the home with bleach - This is incorrect as disinfecting surfaces with bleach is important to kill harmful pathogens.