Nokea
During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?
- A. Temperature increases from 98.8° to 99.0° F.
- B. Pulse rate decreases from 78 to 52 beats/min.
- C. Respiratory rate increases from 16 to 24 breaths/min.
- D. Blood pressure increases from 110/84 to 118/88 mmHg.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?
- A. Orange juice has vitamin C, which deters bacterial growth.
- B. Apple juice is the most useful in acidifying the urine.
- C. Cranberry juice stops pathogens' adherence to the bladder.
- D. Grapefruit juice increases the absorption of most antibiotics.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
- A. Increase intake of foods high in potassium.
- B. Avoid foods high in sodium.
- C. Limit fluid intake to 1.5 liters per day.
- D. Increase intake of foods high in vitamin K.
Correct Answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
- A. The client can hear a whisper from 1 to 2 feet away.
- B. The client can identify an object by touch.
- C. The client can shrug the shoulders against resistance.
- D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When discussing dietary preferences with a client adhering to a vegan diet, which dietary supplement should the nurse encourage the client to include in the dietary plan?
- A. Fiber
- B. Folate
- C. Ascorbic acid
- D. Vitamin B12
Correct Answer: D
Rationale: Vitamin B12 is an essential nutrient that is predominantly found in animal products. Since individuals following a vegan diet do not consume animal products, they are at a higher risk of vitamin B12 deficiency. Therefore, it is crucial for vegans to include a vitamin B12 supplement in their dietary plan to prevent deficiency-related health issues.
When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
- A. Place a sterile drape under the client's buttocks.
- B. Instruct the client to inhale and then exhale slowly.
- C. Discard the gloves and apply new sterile gloves.
- D. Apply a sterile lubricant to the end of the catheter.
Correct Answer: D
Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.