Nokea
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.
You may also like to solve these questions
Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if which of the following is noted?
- A. Increased red blood cell count
- B. Decreased serum ammonia level
- C. Increased protein level
- D. Decreased white blood cell level
Correct Answer: B
Rationale: The correct answer is B: Decreased serum ammonia level. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels through its laxative effect, promoting the excretion of ammonia in the feces. Decreased ammonia levels indicate that the medication is effectively managing the condition. Increased red blood cell count (A), increased protein level (C), and decreased white blood cell level (D) are not directly related to the therapeutic effect of lactulose in hepatic encephalopathy.
The client has had a new colostomy created 2 days earlier. The client is beginning to pass malodorous flatus from the stoma. The nurse interprets that
- A. This indicates inadequate preoperative bowel preparation.
- B. This is a normal, expected event.
- C. The client is experiencing early signs of ischemic bowel.
- D. The client should not have the nasogastric tube removed.
Correct Answer: B
Rationale: The correct answer is B: This is a normal, expected event. After colostomy creation, it is common for clients to pass malodorous flatus from the stoma as the intestines begin to function. This is due to the presence of normal intestinal flora. Choice A is incorrect as preoperative bowel preparation does not directly relate to malodorous flatus post-colostomy. Choice C is incorrect as ischemic bowel presents with more serious symptoms. Choice D is incorrect as nasogastric tube removal is not related to passing flatus from the stoma.
The home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need
- A. Vitamin B12 injections
- B. Vitamin B6 injections
- C. An antibiotic
- D. An antacid
Correct Answer: A
Rationale: The correct answer is A: Vitamin B12 injections. Pernicious anemia results from a lack of intrinsic factor, which is needed for Vitamin B12 absorption. Since the stomach lining produces less intrinsic factor after gastric surgery, the client cannot absorb B12 orally. Therefore, B12 injections are necessary to bypass the need for intrinsic factor. Vitamin B6 injections (B) are not indicated for pernicious anemia. Antibiotics (C) and antacids (D) are not relevant to the treatment of pernicious anemia.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to
- A. Confirm proper nasogastric tube placement.
- B. Observe gastric contents.
- C. Assess fluid and electrolyte status.
- D. Evaluate absorption of the last feeding.
Correct Answer: D
Rationale: Rationale for Correct Answer (D): By assessing for gastric residual before administering another feeding through the nasogastric tube, the nurse can evaluate absorption of the last feeding. If there is a significant amount of residual, it may indicate poor absorption, which could lead to complications such as aspiration. This assessment helps in determining the appropriate timing and amount of the next feeding to prevent complications.
Summary of Incorrect Choices:
A: Confirming proper nasogastric tube placement is typically done using other methods like pH testing or X-ray. This assessment does not directly relate to evaluating absorption.
B: Observing gastric contents may provide information about the patient's gastric secretions but does not specifically help in evaluating the absorption of the last feeding.
C: Assessing fluid and electrolyte status is important but not the primary purpose of checking gastric residual before administering a feeding. This assessment is more focused on monitoring the patient's overall hydration and electrolyte balance.