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A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching?
- A. Avoid high-fat cuts of meat.
- B. Increase your intake of fried foods.
- C. Consume dairy products at every meal.
- D. Eat large meals to avoid frequent digestion.
Correct Answer: A
Rationale: The correct answer is A: Avoid high-fat cuts of meat. Cholelithiasis is the formation of gallstones, often related to high-fat diets. High-fat cuts of meat can trigger gallbladder contractions, leading to pain. The rationale is to reduce fat intake to prevent further gallstone formation. Choices B, C, and D are incorrect. B: Increasing fried foods can exacerbate symptoms due to their high-fat content. C: Consuming dairy products at every meal is not recommended as some dairy products can be high in saturated fats. D: Eating large meals can overload the digestive system, potentially leading to gallbladder discomfort.
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A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
- A. Mild wheezing
- B. Use of accessory muscles
- C. Decreased respiratory rate
- D. Productive cough
Correct Answer: B
Rationale: The correct answer is B: Use of accessory muscles. In status asthmaticus, a severe and life-threatening asthma exacerbation, the client's airways are severely constricted, leading to inadequate air exchange. The use of accessory muscles (such as intercostal and supraclavicular muscles) indicates significant respiratory distress as the body tries to compensate for the difficulty in breathing. Mild wheezing (choice A) may be present in asthma but does not necessarily indicate status asthmaticus. Decreased respiratory rate (choice C) is not consistent with the increased respiratory effort seen in status asthmaticus. Productive cough (choice D) is more indicative of conditions such as bronchitis or pneumonia, not necessarily status asthmaticus.
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
- A. Use only powder-free latex gloves.
- B. Place monitoring cords and tubes in a stockinette.
- C. Avoid using iodine-based antiseptics.
- D. Administer prophylactic antihistamines.
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice D) is not a standard practice for latex allergies and may not prevent an allergic reaction.
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?
- A. The stool will be firm and well-formed.
- B. The stool will have a high volume of liquid.
- C. The stool will be similar to normal bowel movements.
- D. The stool will be hard and difficult to pass.
Correct Answer: B
Rationale: The correct answer is B: The stool will have a high volume of liquid. Following a colectomy with an ileostomy, the client will have fecal output from the small intestine, resulting in a high volume of liquid stool. This is because the large intestine, responsible for absorbing water and forming solid stool, is bypassed with an ileostomy. Choice A is incorrect because the stool will not be firm and well-formed. Choice C is incorrect because the stool will not be similar to normal bowel movements due to the absence of the large intestine. Choice D is incorrect as the stool will not be hard and difficult to pass.
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching?
- A. You will have a urinary catheter for several days.
- B. A PCA pump will be used for postoperative pain control.
- C. You will be discharged the same day as surgery.
- D. You should avoid all fluid intake after surgery.
Correct Answer: B
Rationale: The correct answer is B: A PCA pump will be used for postoperative pain control. This is crucial information for the client undergoing a radical prostatectomy as it ensures effective pain management post-surgery. The use of a PCA pump allows the client to self-administer pain medication within safe limits, promoting better pain control and comfort during the recovery period. It also empowers the client to actively participate in their pain management.
Choice A is incorrect because while the client may have a urinary catheter after surgery, it is not the most crucial information to include in preoperative teaching.
Choice C is incorrect as radical prostatectomy typically requires a hospital stay, not same-day discharge.
Choice D is incorrect as avoiding all fluid intake after surgery is not recommended; adequate hydration is important for recovery.