Nokea
The female client is more than 10% over ideal body weight. Which nursing intervention should the nurse implement first?
- A. Ask the client why she is eating too much.
- B. Refer the client to a gymnasium for exercise.
- C. Have the client set a realistic weight loss goal.
- D. Determine the client's eating patterns.
Correct Answer: D
Rationale: Determining eating patterns identifies triggers and habits, guiding weight loss interventions. Asking why is confrontational, gym referral is premature, and goal-setting follows assessment.
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The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?
- A. Teach the client to limit use of alcohol and drugs containing acetaminophen.
- B. Provide a high-protein, high-carbohydrate diet with three large meals per day.
- C. Wear gloves, mask, and gown when providing the client’s personal cares.
- D. Provide rest periods, alternating this with moderate activity during the day.
Correct Answer: D
Rationale: A. Clients with viral hepatitis should avoid all alcohol and all medications containing acetaminophen, not just limit their use. B. Clients should eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. C. It is not necessary to wear a mask when caring for an individual with hepatitis A. A gown and gloves should be worn when in contact with blood and body fluids. D. Rest is an essential intervention to decrease the liver’s metabolic demands and increase its blood supply. Rest should be alternated with periods of activity to prevent complications and to restore health.
The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright-red blood at home. Which interventions should the nurse implement? List in order of priority.
- A. Assess the client's vital signs.
- B. Insert a nasogastric tube.
- C. Begin iced saline lavage.
- D. Start an IV with an 18-gauge needle.
- E. Type and crossmatch for a blood transfusion.
Correct Answer: A, D,B,C,E
Rationale: 1. Assessing vital signs evaluates hemodynamic stability (priority for bleeding). 2. Starting an IV ensures access for fluids/blood. 3. Inserting an NG tube removes blood and assesses bleeding. 4. Iced saline lavage controls bleeding. 5. Type and crossmatch prepares for transfusion.
The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease. Which statement supports the rationale for administering this medication?
- A. It prevents the final transport of hydrogen ions into the gastric lumen.
- B. It blocks receptors controlling hydrochloric acid secretion by the parietal cells.
- C. It protects the ulcer from the destructive action of the digestive enzyme pepsin.
- D. It neutralizes the hydrochloric acid secreted by the stomach.
Correct Answer: A
Rationale: Proton pump inhibitors (PPIs) inhibit the H+/K+ ATPase pump, preventing hydrogen ion transport into the gastric lumen, thus reducing acid production to promote ulcer healing. Blocking receptors is for H2 antagonists, pepsin protection is for mucosal agents, and neutralization is for antacids.
Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses?
- A. Airborne Precautions.
- B. Standard Precautions.
- C. Droplet Precautions.
- D. Exposure Precautions.
Correct Answer: B
Rationale: Standard Precautions protect against hepatitis viruses (A, B, C, D) by assuming all body fluids are infectious, covering fecal-oral and bloodborne transmission. Other precautions are inappropriate.
The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement?
- A. Provide a low-residue diet.
- B. Rest the client's bowel.
- C. Assess vital signs daily.
- D. Administer antacids orally.
Correct Answer: B
Rationale: During an acute exacerbation of ulcerative colitis, resting the bowel (often via NPO status or clear liquids) reduces inflammation and irritation. A low-residue diet is used in stable phases, daily vital signs are routine, and antacids are irrelevant.