Nokea
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client consumed citrus juice 3 days before the test.
- B. The client takes ibuprofen for headaches.
- C. The client had a hemorrhoidectomy 1 year ago.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Fecal occult blood tests detect heme, but false positives arise from non-colonic bleeding. Ibuprofen, an NSAID, irritates the GI mucosa, causing microbleeds that mimic colorectal sources, a known confounder clients are advised to stop it pre-test. Citrus juice may cause false negatives (vitamin C interferes with guaiac reaction), not positives, and 3 days minimizes impact. A hemorrhoidectomy 1 year ago, healed, doesn't bleed unless recurrent, not suggested. Breast cancer doesn't affect GI bleeding unless metastatic, unlikely here. Ibuprofen's GI effect aligns with testing pitfalls (e.g., ACG guidelines), making it the likely false-positive source to identify.
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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.
Nurses' Notes Day 1: Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up? (Ski accident client)
- A. Findings of right lower extremity assessment
- B. Oxygen saturation
- C. Right pedal pulses
- D. Level of consciousness
- E. Temperature
- F. Pain level
- G. X-ray results
Correct Answer: A,C,F,G
Rationale: Right leg swelling, weak pulses, pain, and X-ray (fracture) indicate urgent issues like compartment syndrome.
Medication Administration Record
Ceftriaxone 2 gm IV BID
Acetaminophen 325 mg PO every 4 hr PRN fever over 39° C (102.2° F)
Guaifenesin 200 mg PO every 4 hr PRN cough
Diagnostic Results
Complete Blood Count:
Hemoglobin 15 g/dL (12 to 16 g/dL)
Hematocrit 45% (37% to 47%)
WBC count 15,000/mm* (5000 to 10,000/mm*)
Basic Metabolic Profile:
Creatinine 2.8 mg/dL (0.5 to 1.1 mg/di)
BUN 19 mg/dL (10 to 20 mg/dL)
Sputum Culture and Sensitivity:
Klebsiella pneumonia
A nurse is reviewing the medical record of a client who has pneumonia. Which of the following information is the priority for the nurse report to the provider?
- A. Sputum results
- B. Creatinine level
- C. Temperature
- D. WBC count
- E. Oxygen saturation
- F. Blood pressure
- G. Respiratory rate
Correct Answer: B
Rationale: Elevated creatinine (2.8 mg/dL) indicates potential kidney injury, a priority over sputum (expected Klebsiella), WBC (infection), or temperature.
A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client asks the nurse why she needs to take four different antituberculotic medications. Which of the following replies should the nurse make?
- A. The organism that causes TB becomes resistant to antituberculotic medications when you only take one medication.
- B. Taking several antituberculotic medications will protect your liver from toxic effects.
- C. People who have a severe form of TB need several antituberculotic medications, but those who have less severe TB need just one medication.
- D. Adverse effects occur more often and are more severe when you take only one antituberculotic medication.
Correct Answer: A
Rationale: Multiple medications prevent resistance in TB treatment, as Mycobacterium tuberculosis can quickly adapt to a single drug, necessitating a combination regimen.
A nurse is reinforcing teaching about high-fiber foods with a client at a health fair. Which of the following foods should the nurse recommend as having the highest fiber content?
- A. 240 mL (8 oz) tomato juice
- B. 240 mL (8 oz) low-fat strawberry Greek yogurt
- C. 1 cup cooked peas
- D. 1 medium banana
Correct Answer: C
Rationale: Fiber content varies widely among foods, and cooked peas top this list. One cup of cooked peas offers about 8-9 grams of fiber, thanks to their legume properties, promoting bowel health and satiety. Tomato juice (8 oz) has roughly 1-2 grams mostly water, low in bulk. Low-fat strawberry Greek yogurt provides minimal fiber (<1 gram), as dairy lacks it naturally, despite added fruit. A medium banana has about 3 grams, decent but far below peas. Recommending peas educates the client on a nutrient-dense, high-fiber choice, aligning with dietary guidelines (e.g., 25-30 grams daily), supporting digestion, and preventing chronic diseases like diverticulosis, making it the best option to highlight.