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A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching?
- A. Take stimulant laxatives daily to relieve constipation.
- B. Avoid fiber-rich foods to prevent bloating.
- C. Increase water intake and use bulk-forming laxatives.
- D. Eat a low-carbohydrate diet to reduce symptoms.
Correct Answer: C
Rationale: The correct answer is C: Increase water intake and use bulk-forming laxatives. This is because increasing water intake helps soften stool, making it easier to pass, and bulk-forming laxatives add bulk to stool, aiding in bowel movements for individuals with IBS-C. Stimulant laxatives (A) can lead to dependency and worsen symptoms. Avoiding fiber-rich foods (B) can exacerbate constipation. Eating a low-carbohydrate diet (D) may not directly address the constipation associated with IBS-C.
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A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first?
- A. Close the pinch clamp on the CVC.
- B. Administer oxygen via non-rebreather mask.
- C. Place the client in Trendelenburg position.
- D. Obtain emergency IV access.
Correct Answer: A
Rationale: The correct answer is A: Close the pinch clamp on the CVC. This action is crucial to prevent air embolism, a potentially life-threatening complication of central venous catheter disconnection. Closing the pinch clamp will stop air from entering the bloodstream and minimize the risk of air embolism. Administering oxygen (B) is important, but closing the pinch clamp takes priority to prevent immediate harm. Placing the client in Trendelenburg position (C) is not recommended as it can worsen air embolism by allowing air to travel to the heart. Obtaining emergency IV access (D) is not the first priority in this situation; preventing air embolism is critical.
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?
- A. Elevated toilet seat
- B. Compression stockings
- C. Heating pad
- D. Nebulizer
Correct Answer: A
Rationale: The correct answer is A: Elevated toilet seat. The nurse should ensure the client has this equipment to facilitate safe and easy toileting post-hip arthroplasty. An elevated toilet seat helps prevent excessive bending at the hip joint, reducing strain and risk of injury. Option B, compression stockings, are used for venous circulation and are not specifically required for hip arthroplasty. Option C, a heating pad, may provide comfort but is not essential for postoperative care. Option D, a nebulizer, is used for respiratory conditions and is not relevant to hip arthroplasty.
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 assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. The client has decreased mucus production.
- B. The clients daily peak expiratory flow (PEF) measures 85% above personal best.
- C. The client has a respiratory rate of 24/min.
- D. The client reports no nighttime coughing.
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma. Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness. Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.