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A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?
- A. Bacteria
- B. Parasites
- C. Blood
- D. Fat
Correct Answer: C
Rationale: The correct answer is C: Blood. A stool guaiac test is used to detect the presence of occult (hidden) blood in the feces, which may indicate gastrointestinal bleeding. This test helps in diagnosing various gastrointestinal conditions such as ulcers, polyps, or colorectal cancer. Detecting blood in the stool is crucial for early diagnosis and intervention. Choices A, B, and D are incorrect as stool guaiac test specifically looks for blood, not bacteria, parasites, or fat in the feces. Blood in the stool is a significant finding that requires further investigation, making it the appropriate response in this scenario.
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A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.
A nurse is assisting in interviewing a client who is being admitted from a long-term care facility. In which of the following situations should the nurse ask a closed-ended question?
- A. Determining if the client is eating a well-balanced diet
- B. Asking the client about his receptiveness to the transfer
- C. Determining how the client completes his ADLs
- D. Asking if the client took his medications this morning
- E. *
Correct Answer: D
Rationale: Closed-ended questions are useful for obtaining specific, factual information, such as whether the client took their medications.
A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
- A. They'll protect your legs and heels from skin breakdown.
- B. They'll help keep you warm immediately after your surgery.
- C. They'll improve your circulation to keep blood from pooling in your legs.
- D. They'll make it easier for you to do leg exercises after your surgery.
Correct Answer: C
Rationale: Correct Answer: C. They'll improve your circulation to keep blood from pooling in your legs.
Rationale:
1. Antiembolism stockings apply gentle pressure to the legs, promoting blood flow.
2. Improved circulation helps prevent blood clots by reducing the risk of venous stasis.
3. By preventing blood pooling, the stockings decrease the chances of deep vein thrombosis.
Incorrect Choices:
A. Skin breakdown prevention is not the primary purpose of antiembolism stockings.
B. Keeping warm is not the main function of these stockings.
D. While leg exercises are important post-surgery, it is not the main reason for using antiembolism stockings.
A nurse in a long-term care facility finds an older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?
- A. Assist the client back into bed and apply restraints.
- B. Call the family and ask them to make arrangements for someone to sit with the client.
- C. Check the client for injuries.
- D. Obtain a prescription for medication to sedate the client.
Correct Answer: C
Rationale: The correct answer is C: Check the client for injuries. This is the most appropriate action as it ensures the client's safety and well-being. By checking for injuries, the nurse can assess the extent of harm and provide necessary medical attention promptly. It also helps in determining if further interventions are required.
Choice A is incorrect because restraints should not be applied without proper assessment. Choice B is incorrect as the priority is to address the immediate physical needs of the client. Choice D is incorrect as sedation should not be the first response to a fall.