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A nurse is providing teaching to 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: Correct Answer: C. Increase water intake and use bulk-forming laxatives.
Rationale: Increasing water intake helps soften stool, easing constipation in IBS-C. Bulk-forming laxatives add fiber to stool, improving bowel movements. Stimulant laxatives (A) can lead to dependency. Avoiding fiber-rich foods (B) worsens constipation. A low-carbohydrate diet (D) may exacerbate constipation.
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A nurse is caring for a client receiving TPN. Which of the following actions should the
nurse take? For each potential nursing intervention, click to specify if the potential intervention
is anticipated, nonessential, or contraindicated for the client.
- A. Request a prescription for insulin
- B. Request for an antibitic to be administered
- C. Decrease the client's oxygen to 1.5 L/min via nasal canula
- D. Have 3 nurses verify the TPN solution prescription
- F. Notify the provider to increase TPN rate/hr
Correct Answer: A,B,C,D
Rationale: [
Anticipated: Request a prescription for insulin, Request for an antibiotic to be administered, Decrease the client's oxygen to 1.5 L/min via nasal cannula, Have 3 nurses verify the TPN solution prescription.
Rationale: A client on TPN may require insulin for glycemic control, antibiotics for infection management, oxygen adjustment for respiratory support, and verification of TPN solution to prevent errors.
Non-essential/Contraindicated: Not applicable as all options are essential in the care of a client receiving TPN.]
A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?
- A. Your breathing pattern causes this.'
- B. This means your lung is fully re-expande '
- C. Suction pressure that is too high causes this.'
- D. This indicates a possible air leak.'
Correct Answer: A
Rationale: The correct answer is A: "Your breathing pattern causes this." The fluctuation in the fluid level of the water-seal chamber of a chest tube system is directly related to changes in intrathoracic pressure during breathing. As the client breathes in and out, the negative pressure in the pleural space increases and decreases, causing the fluid to rise and fall in the water-seal chamber. This movement is a normal physiological response and indicates proper functioning of the chest tube system. Choices B, C, and D are incorrect because they do not accurately explain the reason for the fluid fluctuation in the water-seal chamber. Choice B is incorrect as lung re-expansion does not directly cause the fluid movement. Choice C is incorrect as high suction pressure does not cause this specific phenomenon. Choice D is incorrect as fluid movement does not indicate an air leak.
A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?
- A. Instruct the client to use their elbows to reposition.
- B. Remove the weights before changing the client's bedlinens.
- C. Check pressure points every 12 hr.
- D. Provide the client with a trapeze bar.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a trapeze bar. This is essential for the client in skeletal traction to independently move and reposition themselves safely without putting additional stress on the affected leg. Using elbows (A) can disrupt the traction. Removing weights (B) can lead to complications. Checking pressure points (C) is important but not specific to this situation. The trapeze bar (D) promotes client independence and safety.
A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control. Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors. Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression. Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?
- A. 100 mL of red drainage
- B. 75 mL of greenish-yellow drainage
- C. 200 mL of brown drainage
- D. 150 mL of serosanguineous drainage
Correct Answer: A
Rationale: The correct answer is A: 100 mL of red drainage. Red drainage from an NG tube may indicate active bleeding, which is a concerning finding post-abdominal surgery. This could suggest a potential internal bleeding or vascular injury. The nurse should report this finding to the provider immediately for further evaluation and intervention.
The other choices are incorrect because:
B: 75 mL of greenish-yellow drainage - This could be indicative of bile drainage, which is expected after abdominal surgery.
C: 200 mL of brown drainage - Brown drainage is likely due to old blood or bile, which can be normal in the immediate postoperative period.
D: 150 mL of serosanguineous drainage - Serosanguineous drainage is a mixture of blood and clear fluid, which can be expected after surgery.
Therefore, the correct answer is A due to the potential seriousness of active bleeding indicated by red drainage.