Nokea
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Assist the client to the restroom 30 min after meals.
- B. Limit the client's physical activity until bowel continence is achieved.
- C. Limit the client's fluid intake to 1500 mL/day.
- D. Instruct the client to limit their intake of high-fiber foods
Correct Answer: A
Rationale: Assisting to the restroom 30 minutes after meals leverages the gastrocolic reflex to promote bowel regularity. Limiting activity, fluids, or fiber would hinder continence efforts.
You may also like to solve these questions
A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?
- A. I continue to lose weight.
- B. I have less oily skin.
- C. I no longer feel nervous.
- D. I no longer take a stool softener.
- E. I feel more tired.
- F. My appetite has decreased.
- G. My heart rate is faster.
Correct Answer: C
Rationale: Reduced nervousness indicates propylthiouracil is controlling hyperthyroid symptoms like anxiety.
A nurse is initiating the use of a continuous passive motion (CPM) device for a client following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Set the degree of flexion and extension as tolerated by client.
- B. Pad the CPM device with a thick pillow.
- C. Place the client in high-Fowler's position.
- D. Align the client's joints with the joints on the frame.
Correct Answer: D
Rationale: Aligning the client's joints with the CPM frame ensures proper movement and prevents injury. Flexion/extension should be preset by the provider, padding isn't typically needed, and high-Fowler's position is inappropriate for this therapy.
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take?
- A. Insert a tampon following the procedure.
- B. Reinforce teaching that the procedure involves dilation of the cervix.
- C. Place the client in the Sims' position.
- D. Instruct the client to avoid sexual intercourse until the cervix is healed.
Correct Answer: D
Rationale: A colposcopy is a diagnostic procedure to examine the cervix, vagina, and vulva after an abnormal Pap test, typically involving a speculum and mild discomfort but no cervical dilation. Option A is incorrect because inserting a tampon post-procedure could introduce infection or interfere with healing, especially if biopsies were taken. Option B is wrong as colposcopy does not require cervical dilation; it's a visual inspection, unlike procedures like a D&C. Option C, Sims' position (lateral with knees bent), is not standard lithotomy position is used instead for pelvic access. Option D is correct because advising the client to avoid sexual intercourse until healing prevents irritation, infection, or disruption of any biopsy sites, aligning with post-procedure care guidelines. This instruction supports recovery and ensures accurate follow-up results, making it the most appropriate nursing action.
Nurses' Notes Day 1: Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up? (Ski accident client)
- A. Findings of right lower extremity assessment
- B. Oxygen saturation
- C. Right pedal pulses
- D. Level of consciousness
- E. Temperature
- F. Pain level
- G. X-ray results
Correct Answer: A,C,F,G
Rationale: Right leg swelling, weak pulses, pain, and X-ray (fracture) indicate urgent issues like compartment syndrome.
A nurse is contributing to the plan of care for a client who has HIV. Which of the following interventions should the nurse plan to include?
- A. Provide a diet of pureed foods.
- B. Encourage fluids with meals.
- C. Offer small, frequent meals.
- D. Suggest fresh fruits and vegetables.
Correct Answer: C
Rationale: Clients with HIV often experience nutritional challenges due to symptoms like nausea, fatigue, or opportunistic infections, necessitating a tailored dietary plan. Option A, pureed foods, is suited for swallowing difficulties, not a general HIV need, so it's inappropriate. Option B, encouraging fluids with meals, may dilute gastric juices and worsen digestion or appetite, countering nutritional goals. Option C is correct small, frequent meals help maintain energy, combat weight loss, and accommodate reduced appetite or early satiety common in HIV, supporting immune function and medication tolerance. Option D, fresh fruits and vegetables, sounds healthy but risks infection (e.g., from unwashed produce) in immunocompromised clients, requiring caution or cooking instead. Small, frequent meals align with evidence-based HIV care, optimizing calorie intake and nutrient absorption without overwhelming the digestive system, making it the most effective and safe intervention for this population.