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A nurse is caring for an older adult client who is Chinese and is recovering from a bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?
- A. To regulate blood pressure
- B. To promote digestion
- C. To enhance the immune system
- D. To reduce inflammation
Correct Answer: B
Rationale: The correct answer is B: To promote digestion. Ginger tea is commonly used in Chinese culture to aid digestion and alleviate gastrointestinal issues, making it a suitable choice for a client recovering from a bowel obstruction. Ginger has natural properties that can help stimulate digestive enzymes and improve digestion. This can be beneficial for the client to ease any potential digestive discomfort after the bowel obstruction.
Other choices are incorrect because:
A: Ginger tea is not typically used to regulate blood pressure.
C: While ginger can have some immune-boosting properties, the primary purpose in this scenario is related to digestion.
D: Ginger does have anti-inflammatory properties, but the client's request for ginger tea is more likely for digestive purposes.
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During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to high Fowler's.
- B. Request NPO status for the client.
- C. Check the client's respiratory rate and lung sounds.
- D. Measure the client's temperature.
Correct Answer: C
Rationale: A rapid infusion of IV fluid can cause fluid overload, leading to respiratory distress. Checking respiratory status helps assess for complications.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
- A. Bradypnea
- B. Peripheral edema
- C. Cyanosis
- D. Hypertension
Correct Answer: D
Rationale: Early signs of hypoxia include tachypnea, restlessness, and hypertension due to sympathetic nervous system activation.
A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
- A. Urinary tract infection
- B. Urinary incontinence
- C. Urinary frequency
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Urinary tract infection. The dark amber color, cloudy appearance, and unpleasant odor of the urine indicate a possible infection. Dark amber color suggests concentrated urine due to dehydration, common in UTIs. Cloudiness indicates presence of bacteria or pus, typical in UTIs. Unpleasant odor is often caused by bacteria breaking down urine. Choices B, C, and D are unlikely to cause these specific findings. Urinary incontinence refers to involuntary leakage of urine and does not directly affect urine appearance. Urinary frequency means urinating more often but doesn't typically change urine color or odor. Urinary retention is the inability to empty the bladder completely, which may lead to overflow incontinence, but doesn't directly cause dark amber, cloudy, and foul-smelling urine.