Nokea
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
- A. Flush the tube with sterile sodium chloride solution every 2 hr.
- B. Change the feeding bag every 24 hr.
- C. Position the head of the client's bed at 15°.
- D. Check the gastric residual every 8 hr.
Correct Answer: B
Rationale: Changing the feeding bag every 24 hours prevents bacterial growth and infection, a standard practice for continuous feedings.
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A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.
A nurse is collecting data from a client who has an inadequate dietary intake of fiber. Which of the following findings should the nurse expect?
- A. Constipation
- B. Memory loss
- C. Brittle hair
- D. Bleeding gums
Correct Answer: A
Rationale: Insufficient fiber causes constipation by reducing bowel movement frequency.
A nurse is caring for a client who has a large surgical wound healing by secondary intention. The nurse should recommend a diet high in protein and which of the following nutrients?
- A. Vitamin C
- B. Iron
- C. Potassium
- D. Niacin
Correct Answer: A
Rationale: Vitamin C is essential for collagen synthesis and wound healing. It helps improve the strength of the wound and promotes tissue repair, making it crucial for clients healing by secondary intention.
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Thirst indicates hyperglycemia as the body attempts to excrete excess glucose, causing dehydration.
A nurse is collecting data from a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)
- A. Bradycardia
- B. An increase in platelets
- C. An increase in RBCs
- D. An increase in neutrophils
- E. Localized edema
Correct Answer: D,E
Rationale: D: An increase in neutrophils is a common response to bacterial infection. E: Localized edema indicates inflammation from infection. A, B, and C are not typical infection signs.