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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 implementing a plan of care for a client who has AIDS with recurring pneumonia. Which of the following actions should the nurse take?
- A. Obtain a sputum culture
- B. Administer a chest X-ray
- C. Monitor for fever
- D. Provide oxygen therapy
Correct Answer: A
Rationale: The correct answer is A: Obtain a sputum culture. This is essential to identify the specific pathogen causing the pneumonia in the client with AIDS. By identifying the pathogen, appropriate antibiotic therapy can be initiated promptly. Administering a chest X-ray (B) may help in evaluating the extent of pneumonia but does not address the underlying cause. Monitoring for fever (C) is important but does not provide specific information needed for targeted treatment. Providing oxygen therapy (D) may be necessary but does not address the root cause of the pneumonia.
A nurse evaluates a client's PSA lab results. An increase in PSA indicates what condition?
- A. Benign prostatic hyperplasia
- B. Prostatic cancer
- C. Urinary tract infection
- D. Kidney stones
Correct Answer: B
Rationale: The correct answer is B: Prostatic cancer. PSA levels are commonly used as a marker for prostate cancer. Elevated PSA levels indicate an increased likelihood of prostate cancer. Benign prostatic hyperplasia (choice A) is a non-cancerous condition that can also cause elevated PSA levels but is not indicative of cancer. Urinary tract infection (choice C) and kidney stones (choice D) do not directly affect PSA levels. The other choices (E, F, G) are not provided, but the key is to understand that an increase in PSA specifically points towards the possibility of prostatic cancer.
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.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Preoxygenate the client with 100% oxygen for up to 3 min.
- B. Perform suctioning for no longer than 30 seconds.
- C. Apply suction while inserting the catheter.
- D. Limit oxygen therapy to 50% prior to suctioning.
Correct Answer: A
Rationale: The correct answer is A: Preoxygenate the client with 100% oxygen for up to 3 min. This is essential to prevent hypoxemia during the suctioning procedure. Adequate preoxygenation helps to increase the oxygen reserves in the client's lungs, reducing the risk of oxygen desaturation during and after suctioning. This is particularly important for clients with COPD and an artificial airway, as they are already at risk for hypoxemia due to impaired lung function.
Choices B, C, and D are incorrect:
B: Performing suctioning for no longer than 30 seconds is a general guideline, but it is not specific to clients with COPD and an artificial airway.
C: Applying suction while inserting the catheter is incorrect as this can cause trauma to the airway and increase the risk of infection.
D: Limiting oxygen therapy to 50% prior to suctioning is incorrect as it can lead to hypoxemia in clients with
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
- A. Troponin I, Troponin T, CPK, Myoglobin
- B. Plasma low-density lipoproteins
- C. White blood cell count
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A. Troponin I, Troponin T, CPK, and Myoglobin are all specific laboratory tests used to diagnose a myocardial infarction. Troponin I and T are cardiac biomarkers released into the bloodstream following myocardial cell injury. Creatine phosphokinase (CPK) is an enzyme found in high concentrations in the heart muscle, and elevated levels indicate myocardial damage. Myoglobin is a protein released from damaged muscle cells, including cardiac muscle. These tests provide crucial information to confirm the diagnosis of a myocardial infarction.
Plasma low-density lipoproteins are not specific for diagnosing a myocardial infarction. White blood cell count is not typically used for diagnosing a myocardial infarction, although it may be elevated in response to inflammation associated with heart damage. Blood glucose level is not specific for diagnosing a myocardial infarction and