Nokea
The nurse is assessing a client with hepatitis and notices that the AST and ALT levels have increased. Which of the following statements by the client requires further instruction by the nurse?
- A. I require increased periods of rest.
- B. I follow a low-fat, high carbohydrate diet.
- C. I eat dry toast to relieve my nausea.
- D. I take acetaminophen (Tylenol) for arthritis pain.
Correct Answer: D
Rationale: Acetaminophen (D) is hepatotoxic and should be avoided in hepatitis due to increased liver enzyme levels. Rest (A), a low-fat, high-carbohydrate diet (B), and dry toast for nausea (C) are appropriate.
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A client 2 days ago. What should the nurse include in the client's plan of care? Select all that apply.
- A. When using a walker, encourage the client to point the toes inward.
- B. Position a pillow between the legs to maintain abduction.
- C. Allow the client to be in the supine position or in the lateral position on the unoperated side.
- D. Do not allow the client to bend down to tie or slip on shoes.
- E. Place ice on the incision after physical therapy.
Correct Answer: B,C,D,E
Rationale: Positioning pillows for abduction, appropriate positioning, avoiding bending, and applying ice promote healing and prevent dislocation. Pointing toes inward is incorrect.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which of the following would be an expected outcome for a client with an ileal conduit?
- A. The client verbalizes the understanding that his physical activity must be curtailed.
- B. The client states that he will place an aspirin in the drainage pouch to help control odor.
- C. The client demonstrates how to catheterize the stoma.
- D. The client states that he will empty the drainage pouch frequently throughout the day.
Correct Answer: D
Rationale: Frequent pouch emptying is an expected outcome, preventing complications like leakage or infection. Aspirin is unsafe, and stoma catheterization is not typical.
The nurse should instruct the client with an ileostomy to report which of the following signs and symptoms immediately?
- A. Passage of liquid stool from the stoma.
- B. Occasional presence of undigested food in the effluent.
- C. Absence of drainage from the ileostomy for 6 or more hours.
- D. Temperature of 99.8°F (37.7°C).
Correct Answer: C
Rationale: Absence of drainage from an ileostomy for 6 or more hours may indicate a blockage, requiring immediate reporting. Liquid stool and undigested food are normal, and a slightly elevated temperature is less urgent unless persistent. CN: Physiological adaptation; CL: Synthesize
A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
- A. Assess for potential abuse.
- B. Check for diminished sensations.
- C. Document the findings.
- D. Clean and dress the area.
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
Which of the following diets would be most appropriate in the chronic obstructive pulmonary disease (COPD)?
- A. Low-fat, low-cholesterol diet.
- B. Bland, soft diet.
- C. Low-sodium diet.
- D. High-calorie, high-protein diet.
Correct Answer: D
Rationale: A high-calorie, high-protein diet supports nutritional needs in COPD, where energy expenditure is high and appetite may be low. Other diets are less specific to COPD requirements.