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A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet.
- B. Provide the client with a cold drink prior to defecation.
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day.
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement in clients with spinal cord injuries by promoting peristalsis and aiding in bowel evacuation. Increasing refined grains (choice A) may not directly address the bowel-training program. Providing a cold drink (choice B) may not have a significant impact on bowel movements. Restricting fluid intake to 1,500 mL per day (choice D) can lead to dehydration and worsen constipation.
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A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should turn on the ceiling fan to block out unwanted noise.
- B. I will limit my daily nap to 45 minutes.
- C. I will drink a cup of green tea at bedtime to help me sleep.
- D. I should get out of bed if I cannot fall asleep within an hour of lying down.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Limiting naps to 45 minutes can help improve nighttime sleep in individuals with insomnia by reducing excessive daytime sleepiness and ensuring better sleep quality at night. Longer naps can disrupt the body's natural sleep-wake cycle and make it harder to fall asleep at night. This statement shows an understanding of the importance of sleep hygiene practices for managing insomnia.
Summary:
A: Turning on the ceiling fan may help create white noise, but it does not address the underlying issue of improving sleep quality.
C: Drinking green tea before bedtime can actually worsen insomnia due to its caffeine content.
D: Getting out of bed if unable to sleep within an hour can disrupt the sleep routine and make it harder to fall asleep.
Therefore, the correct choice is B as it directly addresses the management of insomnia by improving sleep habits.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often, since it is not controlling my pain.
- B. Breathing faster will help me keep my mind off of the pain.
- C. It might help me to listen to music while trying to sleep.
- D. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C: "It might help me to listen to music while trying to sleep." This answer indicates that the client understands the preoperative teaching about pain management, as distraction techniques such as listening to music can help manage pain perception. Listening to music can be a non-pharmacological method to alleviate pain and promote relaxation. Choices A and D indicate a lack of understanding as they suggest inappropriate responses to pain. Choice B suggests a distraction technique but not the most effective one. Choices E, F, and G are not provided, but based on the context, they would likely be irrelevant or incorrect in the context of pain management.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is crucial when a client is receiving magnesium sulfate due to its potential to cause muscle weakness and CNS depression. The nurse should assess for hyperreflexia, which indicates magnesium toxicity. Choices B, C, and D are incorrect as they do not directly relate to the therapeutic effect of magnesium sulfate. Pulse rate and urine output may be affected by the medication but are not specific therapeutic effects to monitor for. Proteinuria can be a sign of kidney damage but is not a direct effect of magnesium sulfate therapy.