Nokea
A nurse is caring for a client who has hypocalcemia. For which of the following findings should the nurse monitor?
- A. Tetany
- B. Increased blood pressure
- C. Decreased bowel sounds
- D. Lethargy
- E. Hypotension
- F. Dry skin
- G. Fever
Correct Answer: A
Rationale: Tetany (muscle spasms) is a classic sign of hypocalcemia due to nerve excitability.
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A nurse is contributing to the plan of care for a client who is postoperative following a fasciotomy. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Assist the client to the restroom 30 min after meals.
- C. Offer small, frequent meals.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: C
Rationale: Post-fasciotomy care focuses on pain management, wound healing, and monitoring for complications like infection or compartment syndrome recurrence, not dietary or reproductive restrictions. Offering small, frequent meals supports nutritional needs without overloading the stomach, aiding recovery by maintaining energy for tissue repair, especially if appetite is reduced from pain or medications. A pureed diet is unnecessary unless swallowing is impaired, which isn't indicated here fasciotomy addresses limb pressure, not GI issues. Assisting to the restroom post-meals relates to bowel training, irrelevant to this surgical context. Avoiding sexual intercourse applies to pelvic procedures like colposcopy, not a limb fasciotomy. Small, frequent meals align with postoperative principles, promoting healing and comfort, making it the most relevant intervention for this client's plan of care, enhancing overall recovery without complicating the surgical focus.
A nurse is reinforcing teaching about liquid iron supplements with a client who has anemia. Which of the following information should the nurse include in the teaching?
- A. Take iron supplements between meals for maximum absorption.
- B. Mix iron supplements with milk to prevent staining of the teeth.
- C. Reduce gastric distress by taking iron supplements with an antacid.
- D. Check for orange-colored stools after 4 days of treatment.
Correct Answer: A
Rationale: Iron supplements treat anemia by boosting hemoglobin, but absorption and side effects guide administration. Option A is correct taking iron between meals maximizes absorption since food, especially calcium or fiber, can bind iron, reducing bioavailability. Gastric acid enhances uptake, so an empty stomach is ideal, though some tolerate it with a small snack if irritation occurs. Option B is wrong milk's calcium inhibits absorption and doesn't prevent teeth staining (diluting in juice does). Option C is incorrect antacids raise stomach pH, decreasing iron absorption, and may worsen deficiency. Option D is false iron typically causes black, not orange, stools due to unabsorbed iron oxidation; orange stools could signal another issue. Teaching about between-meal dosing empowers the client to optimize therapy, manage side effects (like constipation or nausea), and monitor for expected changes (e.g., darker stools), ensuring effective anemia treatment.
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following statements indicate the client understands the instructions?
- A. I should increase green leafy vegetables in my diet.
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
Correct Answer: B
Rationale: Iron supplements oxidize in the gut, often turning stools black due to unabsorbed iron a normal, expected effect clients should recognize to avoid alarm. Green leafy vegetables (e.g., spinach) boost dietary iron, but oxalates limit absorption, making this less indicative of supplement-specific teaching. Swelling in feet isn't a typical iron effect edema suggests heart or kidney issues, not anemia treatment. Taking iron 1 hour before meals aids absorption, a good practice, but the question emphasizes understanding therapy outcomes. Black stools confirm the client grasps a common, visible side effect, aligning with education goals (e.g., managing expectations), ensuring adherence and reducing unnecessary worry, making it the clearest sign of comprehension.
A nurse is preparing to perform a sterile dressing change for a client who has a stage III pressure ulcer. Which of the following actions should the nurse plan to take?
- A. Prepare the sterile dressing supplies 30 min before the dressing change.
- B. Don sterile gloves before removing the dressing,
- C. Disinfect the wound bed with alcohol before applying tape.
- D. Offer the client pain medication before the procedure.
Correct Answer: D
Rationale: Offering pain medication beforehand reduces discomfort during the dressing change for a stage III ulcer. Supplies should be prepared just before, sterile gloves are used after removal, and alcohol isn't used on open wounds.
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.