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A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen?
- A. Avoid eating red meat.
- B. Increase fiber intake.
- C. Take an iron supplement.
- D. Drink grapefruit juice.
Correct Answer: A
Rationale: The correct answer is A: Avoid eating red meat. Red meat can cause false positives in fecal occult blood tests due to the presence of heme iron which can be mistaken for blood. Instructing the client to avoid red meat for 3 days prior to collecting the specimen helps to ensure the accuracy of the test results.
Summary:
B: Increasing fiber intake does not directly impact the accuracy of the fecal occult blood test.
C: Taking an iron supplement can interfere with the test results by increasing the amount of iron in the stool, leading to false positives.
D: Drinking grapefruit juice is not relevant to the accuracy of the fecal occult blood test.
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A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the clients face to detect the presence of Chvosteks sign?
- A. Cheek just in front of the ear
- B. Supraorbital ridge
- C. Jaw and mastoid muscle
Correct Answer: A
Rationale: The correct answer is A: Cheek just in front of the ear. Chvostek's sign is a facial spasm elicited by tapping the facial nerve in front of the ear. This sign is indicative of hypocalcemia, as low calcium levels can lead to increased nerve excitability. Tapping on the cheek in this specific area allows the nurse to assess for this sign. Choices B, C, D, E, F, and G are incorrect as they do not target the specific facial nerve area where Chvostek's sign can be elicited. It's important for the nurse to be precise in assessing for this sign to accurately diagnose and manage the client's hypocalcemia.
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching?
- A. You will not be able to eat or drink after the procedure until you are able to cough.
- B. You will need to take deep breaths through your nose during the procedure.
- C. The procedure is painful and sedation will not be used.
- D. You will need to stay on bed rest for 24 hours after the procedure.
Correct Answer: A
Rationale: Correct Answer: A: You will not be able to eat or drink after the procedure until you are able to cough.
Rationale: It is important for the client to know that they will not be able to eat or drink post-bronchoscopy until they can cough effectively to prevent aspiration. This instruction reduces the risk of complications such as aspiration pneumonia. The nurse should emphasize the importance of clearing secretions by coughing before resuming oral intake.
Summary of Incorrect Choices:
B: Taking deep breaths through the nose is not necessary during bronchoscopy; the procedure involves visualization of the airways, not breathing techniques.
C: Bronchoscopy is usually performed under sedation, and the client should be informed about the use of sedation to manage pain and discomfort.
D: Bed rest for 24 hours after bronchoscopy is unnecessary; the client can resume normal activities unless otherwise instructed by the healthcare provider.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?
- A. Bronchoconstriction
- B. Refractory hypoxemia
- C. Pulmonary hypertension
- D. Pleural effusion
Correct Answer: B
Rationale: Correct Answer: B - Refractory hypoxemia.
Rationale: ARDS is characterized by severe hypoxemia that persists despite high levels of oxygen therapy, known as refractory hypoxemia. This occurs due to ventilation-perfusion mismatch and impaired gas exchange in the alveoli. The other choices are not typical manifestations of ARDS:
A: Bronchoconstriction is more commonly seen in asthma or COPD.
C: Pulmonary hypertension may develop as a complication of ARDS but is not a direct manifestation.
D: Pleural effusion may occur in ARDS but is not a defining characteristic.
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply)
- A. Ferrous sulfate
- B. Echinacea
- C. Aspirin
- D. Dextromethorphan
- E. Naproxen
Correct Answer: C, E
Rationale: The correct answer is C (Aspirin) and E (Naproxen). Aspirin and Naproxen are both NSAIDs that can increase the risk of bleeding when taken with warfarin, which is an anticoagulant. The combination can lead to excessive anticoagulation and potential bleeding complications. Ferrous sulfate (A) does not interact significantly with warfarin. Echinacea (B) is an herbal supplement that may have interactions with some medications, but not warfarin specifically. Dextromethorphan (D) is a cough suppressant and does not have a significant interaction with warfarin. In summary, Aspirin and Naproxen should be avoided with warfarin due to the increased risk of bleeding, while the other options do not have significant interactions with warfarin.