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The client who is obese presents to the clinic before beginning a weight loss program. Which interventions should the nurse teach? Select all that apply.
- A. Walk for 30 minutes three (3) times a day.
- B. Determine situations that initiate eating behavior.
- C. Weigh at the same time every day.
- D. Limit sodium in the diet.
- E. Refer to a weight support group.
Correct Answer: A,B,C,E
Rationale: Walking, identifying eating triggers, consistent weighing, and support groups promote sustainable weight loss. Sodium restriction is less critical unless hypertension is present.
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The client in end-stage liver failure has vitamin K deficiency. Which interventions should the nurse implement?
- A. Avoid rectal temperatures.
- B. Use only a soft toothbrush.
- C. Monitor the platelet count.
- D. Use small-gauge needles.
- E. Assess for asterixis.
Correct Answer: A,B,D
Rationale: Vitamin K deficiency impairs clotting, increasing bleeding risk, so avoiding rectal temperatures, using a soft toothbrush, and small-gauge needles minimize trauma. Platelet counts and asterixis are unrelated to bleeding risk.
Which intervention should the nurse implement when administering a potassium supplement?
- A. Determine the client's allergies.
- B. Ask the client about leg cramps.
- C. Monitor the client's blood pressure.
- D. Monitor the client's complete blood count.
Correct Answer: B
Rationale: Asking about leg cramps assesses for hypokalemia symptoms, ensuring the potassium supplement is needed and effective. Allergies, BP, and CBC are less specific.
The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
The client of Chinese ethnicity has diarrhea and refuses to drink the prescribed oral hydration solution, insisting on having chicken broth instead. Which statement about clients of Chinese ethnicity should be the basis for the nurse’s intervention in this situation?
- A. They consider chicken a food with yang qualities.
- B. They believe extra protein is needed to treat diarrhea.
- C. They believe high-sodium foods are needed to treat diarrhea.
- D. They mistrust modern medicine and eat broth to treat disease.
Correct Answer: A
Rationale: A. Loose stools are a yin symptom, which should be treated with foods that have yang qualities, one of which is chicken. B. There is no belief in the Chinese culture related to consuming high-protein foods. C. There is no belief in the Chinese culture related to consuming high-sodium foods. D. The Chinese do not mistrust modern medicine but may combine Western medicine and Chinese herbal medicines to treat disease.
The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?
- A. Start auscultating to the left of the umbilicus.
- B. Turn off the NG suction before auscultation.
- C. Use the bell of the stethoscope for auscultation.
- D. Empty the drainage canister before auscultation.
Correct Answer: B
Rationale: A. When the client has hypoactive bowel sounds, which would be expected in a postsurgical client, the nurse should begin listening over the ileocecal valve in the right lower abdominal quadrant rather than to the left of the umbilicus. The ileocecal valve normally is a very active area. B. When listening for bowel sounds on the client who has an NG tube to suction, the nurse should turn off the suction during auscultation to prevent mistaking the suction sound for bowel sounds. C. The diaphragm of the stethoscope should be utilized for bowel sounds. The bell of the stethoscope should be utilized for abdominal vascular sounds, such as bruits. D. There is no reason to empty the canister before auscultation.