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A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
- A. Avoid foods high in fat.
- B. Avoid foods high in carbohydrates.
- C. Eat a high-protein, low-fat diet.
- D. Increase intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in fat. Biliary colic is caused by gallstones, and high-fat foods can trigger gallbladder contractions leading to pain. Therefore, advising the client to avoid foods high in fat can help prevent biliary colic episodes. Choice B is incorrect as carbohydrates do not directly affect biliary colic. Choice C is incorrect because while a high-protein, low-fat diet may be beneficial for some conditions, it is not specifically recommended for biliary colic. Choice D is incorrect as increasing intake of high-fat foods can worsen symptoms.
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A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Bleeding from the gums
- B. Chest pain
- C. Fatigue
- D. Severe headache
Correct Answer: A
Rationale: The correct answer is A: Bleeding from the gums. Myelosuppression leads to decreased production of blood cells, including platelets, which are essential for clotting. Bleeding from the gums is a common sign of thrombocytopenia, a condition where there are low platelet levels. Chest pain, fatigue, and severe headache are not directly associated with myelosuppression. Monitoring for bleeding tendencies is crucial in clients with myelosuppression to prevent complications like hemorrhage.
A nurse is explaining DIC to a client with septic shock. What should the nurse say?
- A. DIC is caused by abnormal coagulation involving fibrinogen.
- B. DIC is due to a vitamin K deficiency.
- C. DIC is caused by bone marrow suppression.
- D. DIC results from an underactive clotting system.
Correct Answer: A
Rationale: The correct answer is A because Disseminated Intravascular Coagulation (DIC) is characterized by abnormal coagulation involving fibrinogen. In DIC, there is widespread activation of the clotting cascade leading to the formation of microthrombi. This process consumes clotting factors like fibrinogen, leading to bleeding tendencies. Vitamin K deficiency (B) primarily affects the production of clotting factors, but it is not the direct cause of DIC. Bone marrow suppression (C) and an underactive clotting system (D) are not accurate explanations for DIC.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
- A. Do not apply heat to the area of irradiation.
- B. Use sunscreen on the irradiated area.
- C. Apply lotion generously to the irradiated area.
- D. Rub the area with an alcohol-based lotion.
Correct Answer: A
Rationale: Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.
A home health nurse assesses an older adult with vision loss due to glaucoma. What is a safety hazard?
- A. Bright overhead lighting
- B. Presence of scatter rugs in the kitchen
- C. Using contrasting colors in home decor
- D. Wearing slip-resistant shoes
Correct Answer: B
Rationale: The correct answer is B: Presence of scatter rugs in the kitchen. Scatter rugs pose a tripping hazard for individuals with vision loss, especially in areas like the kitchen where spills and slippery surfaces are common. The other choices are incorrect because: A - Bright overhead lighting can actually be beneficial for those with vision loss by improving visibility; C - Using contrasting colors can aid in distinguishing objects and pathways; D - Wearing slip-resistant shoes can help prevent falls.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
- A. Discontinue the existing IV line
- B. Apply warm compresses
- C. Elevate the extremity
- D. Notify the healthcare provider
Correct Answer: A
Rationale: The correct action is to discontinue the existing IV line first. This is crucial because the client is exhibiting signs of infiltration, which can lead to tissue damage and complications. By removing the IV line, further damage can be prevented. Applying warm compresses or elevating the extremity may not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider is important but should not be the first step in this situation.