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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 assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes mellitus, microvascular complications involve damage to small blood vessels. Retinopathy specifically affects the blood vessels in the retina, leading to vision problems. Peripheral neuropathy (A) is a macrovascular complication affecting nerves. Hypertension (B) is a common comorbidity in diabetes but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving larger blood vessels in the brain. Therefore, the presence of retinopathy is a clear indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?
- A. I feel overwhelmed and unsure if I can handle this responsibility.
- B. I changed the floor plan of our home to accommodate my fathers wheelchair.
- C. I wish my siblings would help more with our parents care.
- D. I often feel resentful about the extra responsibilities.
Correct Answer: B
Rationale: The correct answer is B. Changing the floor plan of the home to accommodate the father's wheelchair demonstrates acceptance of the caregiving role. This action shows that the client is willing to make necessary adjustments for their parents' needs, indicating a commitment to the role change.
A: Feeling overwhelmed and unsure indicates resistance to the role change.
C: Wishing for siblings' help suggests a desire to share responsibilities, not necessarily acceptance.
D: Feeling resentful points towards negative emotions, which do not align with acceptance.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?
- A. 0.4 mL
- B. 0.5 mL
- C. 0.6 mL
- D. 0.7 mL
Correct Answer: B
Rationale: To calculate the dose of enoxaparin, first convert the client's weight from pounds to kilograms: 154 lb/2.2 = 70 kg. Then, calculate the dose: 0.75 mg/kg x 70 kg = 52.5 mg. Since the concentration is 60 mg/0.6 mL, divide the dose needed by the concentration: 52.5 mg/60 mg x 0.6 mL = 0.5 mL. Therefore, the correct answer is B (0.5 mL). Choice A is incorrect as it is less than the calculated dose. Choice C is incorrect as it is based on the concentration but does not match the calculated dose. Choice D is incorrect as it is higher than the calculated dose.
A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)?
- A. Hypertension
- B. Diabetes mellitus
- C. Asthma
- D. Hyperthyroidism
Correct Answer: B
Rationale: The correct answer is B: Diabetes mellitus. Diabetes can lead to increased risk for UTIs due to elevated blood sugar levels creating a favorable environment for bacteria to grow in the urinary tract. High blood sugar weakens the immune system, making it harder to fight infections. Hypertension (A) is a condition related to high blood pressure, not directly associated with UTIs. Asthma (C) and hyperthyroidism (D) are not directly linked to an increased risk for UTIs.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the clients risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
- A. Wear a protective gown when suctioning the clients airway.
- B. Monitor for oral secretions every 2 hr.
- C. Provide oral care every 2 hr.
- D. Maintain the client in a supine position.
- E. Assess the client daily for readiness of extubation.
Correct Answer: B, C, E
Rationale: Correct Answer: B, C, E
Rationale:
- Monitoring for oral secretions every 2 hr helps prevent aspiration of secretions, reducing the risk of VAP.
- Providing oral care every 2 hr reduces the bacterial load in the mouth, decreasing the risk of VAP.
- Assessing the client daily for readiness of extubation allows for timely removal of the ventilator, reducing the duration of ventilation and lowering the risk of VAP.
Incorrect Choices:
- Wearing a protective gown when suctioning the client's airway does not directly decrease the risk of VAP.
- Maintaining the client in a supine position may increase the risk of aspiration and VAP.