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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. Encourage a maximum fluid intake of 1,500 ml per day.
- B. Increase the intake of refined grains in the client's diet.
- C. Provide the client with a cold drink prior to defecation.
- D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
Correct Answer: D
Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.
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A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?
- A. You should keep your baby's identification band on at all times.
- B. It is safe to leave your baby unattended in the room.
- C. Identification bands should be applied immediately after birth.
- D. Avoid public announcements about your baby's birth.
Correct Answer: D
Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.
A nurse is providing care to a client who has thrombocytopenia. Which of the following actions should the nurse take?
- A. Encourage the client to floss daily.
- B. Remove fresh flowers from the client's room.
- C. Provide the client with a stool softener.
- D. Avoid serving raw vegetables.
Correct Answer: C
Rationale: The correct answer is C: Provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Providing the client with a stool softener helps prevent constipation, reduces the need for straining during bowel movements, and ultimately decreases the risk of bleeding. Choice A is incorrect as flossing daily does not directly address the issue of bleeding risk associated with thrombocytopenia. Choice B is incorrect as removing fresh flowers from the client's room is more related to the risk of infection rather than bleeding in thrombocytopenia. Choice D is incorrect as avoiding serving raw vegetables does not directly impact the risk of bleeding in clients with thrombocytopenia.
A client is being taught about a new prescription for furosemide. Which of the following statements by the client indicates an understanding of the teaching?
- A. This medication will decrease my potassium levels.
- B. I should eat a banana every day to increase my potassium intake.
- C. I will stop taking this medication if I experience a cough.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: D
Rationale: The correct answer is D. Clients taking furosemide should avoid alcohol because it can lead to dehydration and potential interactions with the medication. Choices A and B are incorrect because furosemide is a diuretic that can actually lower potassium levels, so the client should not expect an increase in potassium levels or solely rely on bananas for potassium intake. Choice C is incorrect because a cough is not a common side effect of furosemide and should not be a reason to stop taking the medication.
A healthcare provider is providing dietary teaching to a client who has osteoporosis. Which of the following foods should the healthcare provider recommend as the best source of calcium?
- A. Broccoli
- B. Cheddar cheese
- C. Almonds
- D. Fortified orange juice
Correct Answer: B
Rationale: Cheddar cheese is a rich source of calcium and should be recommended to clients with osteoporosis. While broccoli and almonds also contain calcium, cheddar cheese provides a higher amount per serving. Fortified orange juice may contain added calcium, but it is not as concentrated a source as cheddar cheese. Therefore, the best choice for a client with osteoporosis seeking a high calcium food is cheddar cheese.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis.
- B. Administer flumazenil to the client.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions for the client.
Correct Answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.