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The client was treated for constipation 1 month earlier. On a return clinic visit, which statement would best assist the nurse to evaluate that the client is no longer constipated?
- A. I drink 2000 milliliters of fluids daily, including drinking 4 ounces of prune juice.
- B. I have had a soft-formed stool without straining every other day for the past 2 weeks.
- C. I needed to give myself only one disposable enema since my appointment last month.
- D. I have a lot of discomfort from hemorrhoids during my daily bowel movements.
Correct Answer: B
Rationale: B: Soft stools every other day without straining indicates resolved constipation. A: Fluid intake prevents constipation but doesn't confirm resolution. C: Enema use doesn't confirm regular bowel function. D: Hemorrhoid discomfort doesn't clarify stool frequency or consistency.
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The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client's PEG tube was changed 6 months ago.
- D. The client's indwelling urinary catheter was last changed 5 days ago.
Correct Answer: A
Rationale: Bedridden clients should be repositioned every 2 hours to prevent skin breakdown.
The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action?
- A. Resume the urine collection and collect one additional voided specimen.
- B. Discard the urine collected and begin a new urine collection immediately.
- C. Complete the urine collection and send all urine collected to the laboratory.
- D. Dispose of the urine collected and reschedule the test to begin the next morning.
Correct Answer: B
Rationale: B: A discarded void invalidates the collection; restarting ensures accuracy. A: Adding a void causes inaccuracies. C: Missing a void compromises results. D: Rescheduling is unnecessary as the test can start anytime.
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
- A. turning out the room light and closing the door
- B. tiring the child during the evening with play exercises
- C. identifying the child's home bedtime rituals and following them
- D. encouraging visitation by friends during the evening
Correct Answer: C
Rationale: Preschool-age children require bedtime rituals that should be followed in the hospital if possible. Choice 1 increases a child's fear. Choices 2 and 4 do not promote sleep.
The hospitalized client is able to stand to use an electronic digital scale for obtaining the client's prescribed daily weight. Which nursing interventions best ensure that the client's daily weight is accurate? Select all that apply.
- A. Ask the client to wear supportive shoes before stepping on the scale
- B. Ensure that the scale is calibrated and “zeroed†before a weight is obtained
- C. Weigh the client by moving the sliding indicator until the scale balances
- D. Weigh the client at different times of the day and then average the weights
- E. Take the weight as soon as the client wakens in the morning and after voiding
Correct Answer: B,E
Rationale: B: Calibration ensures accuracy. E: Weighing post-voiding at the same time daily standardizes results. A: Shoes add weight. C: Sliding indicators are for balance scales. D: Averaging weights reduces accuracy.
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.