Nokea
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Dried fruits
- B. Dried peas
- C. Eggs
- D. Pasta
Correct Answer: C
Rationale: The correct answer is C: Eggs. Eggs are a good source of protein, which is important for clients with a colostomy to promote healing and overall health. They are easily digestible and less likely to cause issues like blockages or gas. Dried fruits (choice A) and dried peas (choice B) can be high in fiber and may lead to digestive problems for colostomy clients. Pasta (choice D) can also be difficult to digest and may cause discomfort. Eggs are a versatile and nutritious option that can be beneficial for clients with a colostomy.
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A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include?
- A. Assist the client to sit upright in a chair for 4 hours at a time.
- B. Expect clear drainage on the spinal dressing.
- C. Log roll the client every 2 hours.
- D. Perform neurological checks every 8 hours.
Correct Answer: C
Rationale: The correct answer is C: Log roll the client every 2 hours. This action is crucial for preventing complications such as pressure ulcers and maintaining spinal alignment post spinal fusion surgery. Log rolling helps to keep the spine in proper alignment and reduces the risk of injury to the surgical site. Assisting the client to sit upright for 4 hours at a time (choice A) can put excessive pressure on the surgical site and hinder the healing process. Expecting clear drainage on the spinal dressing (choice B) is not appropriate as drainage may vary and is not necessarily an indicator of infection. Performing neurological checks every 8 hours (choice D) is important but should be done more frequently in the immediate postoperative period.
A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include?
- A. You can expect swelling of the ankles while taking this medication.
- B. Do not take this medication on an empty stomach.
- C. Limit your fluid intake to meal times.
- D. Increase your daily intake of dietary fiber.
Correct Answer: D
Rationale: The correct answer is D: Increase your daily intake of dietary fiber. Verapamil, a calcium channel blocker used for angina, can cause constipation as a side effect. Increasing dietary fiber helps prevent constipation by promoting bowel regularity. This instruction is important for the client's overall well-being and medication compliance.
A: Swelling of the ankles is not a common side effect of verapamil.
B: Verapamil can be taken with or without food, so taking it on an empty stomach is not necessary.
C: There is no need to limit fluid intake to meal times while taking verapamil.
A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula.
- B. A school-age child who has diabetes mellitus and requires blood glucose monitoring.
- C. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
- D. A toddler who has both arms in casts and needs to be fed his breakfast.
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause respiratory distress. Assessing the oxygenation status is a priority to ensure the infant is receiving adequate oxygenation. This can prevent potential complications such as respiratory failure. The other clients have important needs but do not have immediate life-threatening conditions requiring urgent assessment. The school-age child with diabetes requires monitoring but can wait a little longer. The adolescent in sickle cell crisis ready for discharge instructions can be assessed after ensuring the infant's immediate needs are addressed. The toddler with both arms in casts needing feeding can also wait since feeding can be done after the infant's urgent assessment.
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.