Nokea
The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?
- A. The spouse holds the irrigating solution about 18 inches above the stoma.
- B. The client is sitting on the toilet seat for the irrigation.
- C. The spouse is using 1000 mL of irrigating solution.
- D. The spouse uses petroleum jelly to lubricate the tip of the catheter.
Correct Answer: D
Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.
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The nurse is talking with the parent of an adolescent client with suspected bulimia nervosa. Which of the following statements by the client's parent would be consistent with bulimia nervosa?
- A. I have noticed my child cuts food into small pieces and pushes it around the plate.
- B. I found several empty boxes of laxatives in my child's bedroom.
- C. My child has lost 20 lb (9.1 kg) in the past 2 months.
- D. My child has stopped exercising.
Correct Answer: B
Rationale: Laxative abuse is a common purging behavior in bulimia nervosa. Cutting food and pushing it around is more typical of anorexia. Significant weight loss is less common in bulimia, as weight often fluctuates. Reduced exercise isn't characteristic.
Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?
- A. Potassium
- B. Sodium
- C. Chloride
- D. Calcium
Correct Answer: B
Rationale: Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.
The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti and meatballs
Correct Answer: C
Rationale: Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:
- A. apply heat to the affected leg for 10 minutes out of every hour for the next 24 hours.
- B. sit with the legs up or walk but avoid prolonged standing and sitting with the feet down.
- C. avoid weight bearing on the affected leg for the next week.
- D. remove the compression bandages after 24 hours.
Correct Answer: B
Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.