Nokea
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
- A. Sit on the toilet 30 minutes after eating a meal.
- B. Increase your fluid intake to help with bowel movements.
- C. Exercise regularly to improve bowel function.
- D. Consume more high-fiber foods to prevent constipation.
Correct Answer: A
Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.
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The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?
- A. I should take the supplement with milk to increase absorption.
- B. I should expect my stools to turn black while taking this supplement.
- C. I should take the supplement with a full glass of water.
- D. I should take the supplement on an empty stomach.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse's priority action?
- A. Administer pain medication 45 minutes prior to dressing change.
- B. Change the dressing quickly to minimize pain.
- C. Provide reassurance to the client that the pain will pass.
- D. Use a less painful dressing technique.
Correct Answer: A
Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.
While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:
- A. Ask the client if they are choking
- B. Perform abdominal thrusts
- C. Call for emergency help
- D. Check the client's airway
Correct Answer: A
Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?
- A. Lymphedema and nerve palsy
- B. Hearing loss and ataxia
- C. Headaches and vomiting
- D. Abdominal mass and weakness
Correct Answer: D
Rationale: Neuroblastoma, a common solid tumor in children, often presents with symptoms related to the mass effect it causes. Abdominal mass and weakness are classic signs of neuroblastoma due to the tumor originating in the adrenal glands near the kidneys and potentially compressing nearby structures. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more common in conditions affecting the central nervous system rather than neuroblastoma. Headaches and vomiting (Choice C) are nonspecific symptoms and are less commonly linked to neuroblastoma compared to the characteristic abdominal findings.
A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?
- A. Apply the cuff above the client's antecubital fossa.
- B. Use a cuff with a width that is about 60% of the client's arm circumference.
- C. Have the client sit with their arm resting at the level of their heart.
- D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.
Correct Answer: A
Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.