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A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?
- A. Administer enemas 2 days before the procedure
- B. Do not eat or drink anything except water for 12 hr. before the procedure.
- C. Restrict the diet to clear liquids for 1 to 3 days before the procedure.
- D. Expect the provider to schedule another procedure to remove any polyps
Correct Answer: B
Rationale: A 12-hour fast with only water prepares the colon adequately for a colonoscopy, reflecting standard protocol and client understanding.
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A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
- E. Avoid drinking water.
- F. Expect bright red urine indefinitely.
- G. Ignore bladder spasms.
Correct Answer: B
Rationale: Waiting 6 weeks allows healing; ibuprofen may increase bleeding, tub baths risk infection, and driving depends on recovery.
A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?
- A. Encourage three large meals daily.
- B. Administer an antiemetic after each meal.
- C. Season foods with spices.
- D. Provide a high-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet addresses malnutrition in AIDS by meeting increased metabolic needs. Large meals may be overwhelming, antiemetics are given before meals if needed, and spices may not be tolerated.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- C. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- D. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
Correct Answer: D
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range and increases the risk of bleeding during a liver biopsy, so it should be reported. The other values are within normal limits and do not pose an immediate concern.
A nurse is reinforcing teaching with a client who wants to lose 0.9 kg (2 lb) of body fat per week. The nurse knows that 0.45 kg (1 lb) of body fat is equal to 3500 calories. The nurse should instruct the client to reduce his daily caloric intake by how many calories?
Correct Answer: 1000
Rationale: Calculation: 2 lb × 3,500 cal/lb = 7,000 cal/week; 7,000 ÷ 7 = 1,000 cal/day reduction achieves the weight loss goal.
A nurse is contributing to the plan of care for a client who has viral meningitis. Which of the following interventions should the nurse recommend?
- A. Measure the client's intake and output every 8 hr.
- B. Dim the lighting in the client's room.
- C. Monitor the client's temperature every 6 hr.
- D. Initiate contact precautions for the client.
Correct Answer: B
Rationale: Dimming the lighting reduces photophobia, a common symptom of viral meningitis, improving client comfort. Intake/output and temperature monitoring are useful but less specific, and contact precautions are not typically required for viral meningitis.