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A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following actions should the nurse take to promote comfort?
- A. Encourage the client to ambulate every 2 hr.
- B. Offer the client a high-fat meal.
- C. Apply a heating pad to the client's abdomen.
- D. Provide the client with a pillow to splint the incision during coughing.
Correct Answer: D
Rationale: Splinting the incision with a pillow reduces pain during coughing. Ambulation aids recovery but isn't comfort-focused, high-fat meals are avoided, and heating pads risk complications.
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A nurse is reinforcing teaching with a client who has a new prescription for metoprolol. Which of the following statements should the nurse include?
- A. Take this medication with a high-fiber meal.
- B. You might feel tired while taking this medication.
- C. You need to avoid caffeine.
- D. You can stop taking this medication if your pulse is normal.
Correct Answer: B
Rationale: Metoprolol can cause fatigue, a side effect to anticipate. Fiber meals, caffeine avoidance, and stopping based on pulse aren't recommended.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for metformin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. You might experience a metallic taste in your mouth.
- C. You should stop taking this medication if you feel shaky.
- D. You need to limit your protein intake while taking this medication.
Correct Answer: B
Rationale: Metformin can cause a metallic taste, a common side effect to anticipate. It's taken with meals, shakiness requires glucose, and protein limits aren't needed.
A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 4 hr.
- B. Flush the tube with water every 12 hr.
- C. Position the client supine during feeding.
- D. Change the feeding bag every 48 hr.
Correct Answer: A
Rationale: Checking residual volume every 4 hours assesses tolerance, preventing aspiration. Flushing is more frequent, supine positioning risks aspiration, and bags change every 24 hours.
A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching?
- A. Limit the client's social interactions.
- B. Encourage the client to be assertive.
- C. Assume responsibility for making the client's decisions.
- D. Maintain a verbal no-harm contract with the client.
Correct Answer: B
Rationale: Encouraging assertiveness promotes independence, countering dependency tendencies. Limiting interactions or making decisions for the client reinforces dependence, and no-harm contracts are unrelated.
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.