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A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates?
- A. Milk, eggs, and cheese
- B. Chicken, green beans, and apples
- C. Rice, potatoes, and oranges
- D. Butter, oils, and avocados
Correct Answer: C
Rationale: Rationale: Carbohydrates are the primary source of energy for the body. Rice, potatoes, and oranges are all high in carbohydrates, providing energy for daily activities. Milk, eggs, and cheese are high in protein and fats, not carbs. Chicken, green beans, and apples contain some carbs but not as high as the options in C. Butter, oils, and avocados are high in fats and low in carbs. Therefore, Option C is correct as it consists of foods with the highest level of carbohydrates.
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A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care?
- A. Perform range-of-motion (ROM) exercises at least two to three times daily.
- B. Auscultate breath sounds at least every 2 hr.
- C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
- D. Apply anti-embolic stockings.
Correct Answer: B
Rationale: The correct answer is B: Auscultate breath sounds at least every 2 hr. This is the priority action because immobile clients are at increased risk for developing pneumonia due to decreased lung expansion. Regular auscultation helps in early detection of respiratory complications. Performing ROM exercises (A) is important but not the priority. Fluid intake (C) and anti-embolic stockings (D) are essential in immobile clients but monitoring breath sounds takes precedence over these interventions.
A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?
- A. Use an alcohol-based agent to perform hand hygiene when caring for the client.
- B. Obtain a blood specimen to test for C. difficile.
- C. Place the client on contact precautions.
- D. Place a surgical mask on the client during transport.
Correct Answer: C
Rationale: The correct answer is C: Place the client on contact precautions. This is necessary because C. difficile is transmitted through contact with contaminated surfaces or objects. Placing the client on contact precautions helps prevent the spread of the infection to others.
A: Using an alcohol-based agent for hand hygiene is important, but placing the client on contact precautions is more specific to preventing the spread of C. difficile.
B: Obtaining a blood specimen is not typically done to diagnose C. difficile. Stool samples are usually collected.
D: Placing a surgical mask on the client during transport is not necessary for preventing the spread of C. difficile.
In summary, placing the client on contact precautions is the most appropriate action to prevent the transmission of C. difficile infection to others.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All that Apply.)
- A. Assess the client every 4 hours.
- B. Place a fall-risk identification band on the client's wrist.
- C. Keep the client's room dark at night.
- D. Teach the client to use the call light.
- E. Keep the client's bed in the lowest position.
Correct Answer: B,D,E
Rationale: The correct actions for a client at risk for falls are: placing a fall-risk identification band on the wrist (B) for staff awareness, teaching the client to use the call light (D) for assistance, and keeping the bed in the lowest position (E) to prevent injuries from falls. Assessing the client every 4 hours (A) may not directly prevent falls. Keeping the room dark at night (C) may increase fall risk. The other choices are not provided.
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?
- A. Encouraging the client to consume a high-protein diet
- B. Performing hand hygiene before, during, and after direct contact with the client
- C. Placing the client in a room with positive-pressure airflow
- D. Changing the client's bed linens each day
Correct Answer: B
Rationale: Correct Answer: B - Performing hand hygiene before, during, and after direct contact with the client
Rationale: Hand hygiene is a crucial infection control measure to prevent the transmission of infections. By washing hands before, during, and after contact with the client, the nurse reduces the risk of spreading the infection to themselves or other individuals. It helps to eliminate pathogens that may be present on the hands and prevents cross-contamination. This practice is supported by evidence-based guidelines and is a fundamental aspect of infection prevention in healthcare settings.
Summary of Incorrect Choices:
A: Encouraging a high-protein diet is important for the client's nutrition but does not directly prevent the transmission of the infection.
C: Placing the client in a room with positive-pressure airflow may be suitable for specific conditions but does not address the immediate need for infection prevention.
D: Changing the client's bed linens each day is essential for maintaining cleanliness but does not directly prevent the transmission of the infection.
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?
- A. Obtain the client's consent.
- B. Explain the procedure to the client if they do not understand.
- C. Witness the client's signature.
- D. Explain the risks and benefits of the procedure.
Correct Answer: C
Rationale: The correct answer is C: Witness the client's signature. This is crucial to ensure that the client is voluntarily giving consent for the surgical procedure. By witnessing the signature, the nurse confirms that the client is fully informed and agrees to the procedure. Obtaining consent (Choice A) is important but witnessing the client's signature (Choice C) validates that the consent is authentic. Explaining the procedure (Choice B) and risks and benefits (Choice D) are essential parts of the informed consent process but witnessing the signature is the final step to confirm the client's agreement.