Nokea
A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?
- A. Puffed rice cereal
- B. Tomato juice
- C. Bran muffin
- D. Cottage cheese
- E. None
- F. None
Correct Answer: C
Rationale: Bran muffins are high in fiber, which promotes bowel regularity and indicates understanding.
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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
- A. Apply suction while inserting the catheter
- B. Apply intermittent suction for 30 seconds
- C. Insert the catheter 10 cm (4 in)
- D. Wait 1 min between suctioning attempts
Correct Answer: D
Rationale: Waiting 1 minute between attempts allows oxygenation and prevents hypoxia.
A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?
- A. Place the bedside table 2 feet away from the bed.
- B. Keep lighting in the home dim.
- C. Place area rugs on slick floor surfaces.
- D. Move the client's bed to the main floor of the house.
Correct Answer: D
Rationale: Moving the bed to the main floor reduces stair-related fall risks.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
The client states that she slipped on some water outside of the shower.
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
- A. Notify the client's provider.
- B. Measure the client's vital signs.
- C. Document the fall in the client's medical record.
- D. Complete an incident report.
Correct Answer: B
Rationale: Measuring vital signs assesses for immediate injury, the priority action.