Nokea
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.
You may also like to solve these questions
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Inform the client of the adverse effect of diarrhea.
- B. Monitor the client for weight loss.
- C. Advise the client about increased dry mouth.
- D. Check the client for increased hypopigmentation under the patch.
Correct Answer: C
Rationale: Clonidine, an antihypertensive, commonly causes dry mouth as a side effect, and advising the client about this is appropriate for the care plan. Diarrhea, weight loss, and hypopigmentation are not typical effects associated with transdermal clonidine.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?
- A. Advise the client about increased dry mouth.
- B. Monitor the client for weight loss.
- C. Inform the client of the adverse effect of diarrhea.
- D. Check the client for increased hypopigmentation under the patch.
- E. Monitor for hypertension.
- F. Advise about insomnia.
- G. Check for tachycardia.
Correct Answer: A
Rationale: Dry mouth is a common side effect of clonidine; diarrhea and hypopigmentation aren't typical.
Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Exhibit 5
Diagnostic Results
1000:
Hct 24% (37% to 47%)
Hgb 8 g/dL (12 to 16 g/dL)
RBC count 3 x 10⁶ µL (4.2 to 5.4 x 10⁶ µL)
Ferritin 8 ng/mL (10 to 150 ng/mL)
WBC count 9,000/mm³ (5,000 to 10,000/mm³)
Platelet count 180,000/mm³ (150,000 to 400,000/mm³)
Vitamin B₁₂ 159 pg/mL (160 to 950 pg/mL)
1030:
Stool for fecal occult blood negative
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following instructions should the nurse include?
- A. Take an antacid within 30 min after medication administration.
- B. Increase sources of fiber in the diet.
- C. Take the medication with a source of vitamin C.
- D. Increase intake of milk and dairy products.
- E. Take the medication on an empty stomach.
Correct Answer: C
Rationale: Iron deficiency anemia treatment hinges on maximizing iron absorption. Taking the medication with vitamin C enhances uptake ascorbic acid converts ferric to ferrous iron, boosting bioavailability in the acidic stomach environment, a cornerstone of anemia management. Antacids raise gastric pH, binding iron and reducing absorption, counterproductive to correcting deficiency. Increasing fiber mitigates constipation, a side effect of iron, but isn't the primary administration focus. Milk and dairy, high in calcium, inhibit iron absorption by competing for uptake sites, worsening anemia if paired with supplements. Vitamin C's synergistic effect backed by dietary guidelines optimizes therapy, especially critical with low ferritin (8 ng/mL, Exhibit 1), empowering the client to improve hemoglobin efficiently while minimizing common pitfalls, making it the essential instruction.
A nurse is reinforcing teaching for a client who was admitted with an exacerbation of COPD. Which of the following should the nurse include in the client teaching?
- A. You should consume small, frequent meals each day.
- B. You should decrease your caloric intake by 200 calories per day.
- C. You should increase your oxygen to 5 liters per minute if you have shortness of breath.
- D. You should discontinue your prednisone when your symptoms improve.
Correct Answer: A
Rationale: Small, frequent meals reduce diaphragm pressure and breathing effort in COPD. Caloric reduction isn't advised, oxygen adjustments need orders, and prednisone requires tapering.
A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
- A. Absence of Chvostek's sign
- B. Presence of Kussmaul respirations
- C. Presence of diaphoresis
- D. Absence of urinary ketones
Correct Answer: B
Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.