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A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
- A. Increase calcium intake
- B. Avoid foods high in potassium
- C. Drink 3 L of fluid every day
- D. Limit vitamin C intake
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (Choice A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (Choice B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (Choice D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.
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A nurse cares for a client on ethambutol therapy for tuberculosis. What should be monitored?
- A. Hearing loss
- B. Visual acuity
- C. Liver function
- D. Blood glucose
Correct Answer: B
Rationale: The correct answer is B: Visual acuity. Ethambutol can cause optic neuritis, leading to visual disturbances. Monitoring visual acuity is crucial to detect any changes early.
Incorrect choices:
A: Hearing loss is associated with other medications for TB, not ethambutol.
C: Liver function is not typically affected by ethambutol.
D: Blood glucose is not directly impacted by ethambutol therapy.
In summary, monitoring visual acuity is essential due to the potential optic nerve toxicity of ethambutol, making it the most relevant parameter to monitor in this case.
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?
- A. Avoid foods prepared with tap water.
- B. Use purified water for drinking.
- C. Limit intake of fried foods.
- D. Get vaccinated for hepatitis C.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods prepared with tap water. Tap water in certain regions may be contaminated with hepatitis-causing viruses. Using bottled or purified water for drinking alone (choice B) may not prevent exposure through food preparation. Limiting fried foods (choice C) is unrelated to preventing viral hepatitis. While getting vaccinated for hepatitis C (choice D) is important, it is not directly related to preventing exposure through contaminated tap water. Therefore, the most effective preventive measure is to avoid foods prepared with tap water to reduce the risk of acquiring viral hepatitis.
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 explains to a client why two chest tubes are in place after a lobectomy. What is the lower chest tube for?
- A. Draining air from the pleural space
- B. Draining blood and fluid from the pleural space
- C. Providing oxygen directly to the lungs
- D. Preventing lung collapse
Correct Answer: B
Rationale: The lower chest tube after a lobectomy is to drain blood and fluid from the pleural space. This is crucial to prevent complications such as fluid accumulation, which can lead to infection or impaired lung expansion. The other choices are incorrect because: A) Draining air is usually done by the upper chest tube, C) Providing oxygen does not require a chest tube, and D) Preventing lung collapse is more related to the function of the upper chest tube in maintaining negative pressure in the pleural space.
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.