Nokea
The nurse avoided a romantic tie with Mr. Gary. This is an example of?
- A. Professional boundaries
- B. Cultural sensitivity
- C. Justice
- D. Fidelity
Correct Answer: A
Rationale: Avoiding romance is professional boundaries (A) keeping limits, per ethics. Sensitivity (B) culture, justice (C) fairness, fidelity (D) promises not boundary-specific. A fits the nurse's ethical distance, ensuring professionalism, making it correct.
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All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except:
- A. Increased oxidative enzyme levels
- B. Alcohol taken with medication
- C. Medications containing magnesium
- D. Decreased serum albumin
Correct Answer: A
Rationale: Oxidative enzyme levels decrease with age, not increase, affecting drug metabolism.
A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.
A client with lactose intolerance is being taught about dietary management by a nurse. Which statement by the client shows an understanding of the teaching?
- A. I should avoid foods that contain lactose.
- B. I should increase my intake of dairy products.
- C. I should avoid foods that contain gluten.
- D. I should increase my intake of high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: 'I should avoid foods that contain lactose.' Lactose intolerance results from the inability to digest lactose, a sugar found in dairy products. Avoiding foods that contain lactose is essential in managing symptoms like bloating, diarrhea, and abdominal pain. Choice B is incorrect because increasing dairy intake would worsen symptoms. Choice C is incorrect because gluten is unrelated to lactose intolerance. Choice D is incorrect because high-fiber foods are beneficial for other conditions but do not specifically address lactose intolerance.
A healthcare provider is caring for a client who is receiving IV therapy via a peripheral catheter. The healthcare provider should identify that which of the following findings is an indication of infiltration?
- A. Redness at the infusion site
- B. Edema at the infusion site
- C. Warmth at the infusion site
- D. Oozing of blood at the infusion site
Correct Answer: B
Rationale: Edema at the infusion site is an indication of infiltration, where fluid leaks into the surrounding tissues causing swelling. This can compromise the delivery of medication and fluids, potentially leading to complications. Redness, warmth, and oozing of blood are more suggestive of inflammation or infection rather than infiltration. Infiltration requires prompt recognition and intervention to prevent further issues with the IV therapy.
A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30°
- B. Flush the tube with 50 mL of water every 2 hours
- C. Replace the feeding bag and tubing every 72 hours
- D. Check the client's gastric residual every 8 hours
Correct Answer: A
Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.