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The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
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A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.
- A. Document this communication in the electronic health record
- B. Encourage the client to discuss this decision with the health care proxy
- C. Facilitate completion of an advance directive that reflects the client's decision
- D. Obtain a signed informed consent from the client
- E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order
Correct Answer: A, B, C
Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.
The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to:
- A. Continue the same caloric intake and decrease his activity level
- B. Increase his activity level to stimulate his appetite
- C. Increase the amount of complex carbohydrates and decrease the amount of fat intake
- D. Decrease the amount of complex carbohydrates while increasing calories, protein, fat, vitamins, and minerals
Correct Answer: D
Rationale: Clients with COPD often have increased metabolic demands and may lose weight. To maintain optimal weight, they should increase overall caloric intake, including protein, fat, vitamins, and minerals, while possibly decreasing complex carbohydrates to balance the diet. Answer A is incorrect as decreasing activity is not beneficial. Answer B may not be feasible due to respiratory limitations. Answer C does not address the need for increased calories and nutrients.
The practical nurse is collaborating with the registered nurse to form a care plan for a client with a possible diagnosis of Guillain-Barré syndrome. The nurse should give priority to which client assessment?
- A. Orthostatic blood pressure changes
- B. Presence or absence of knee reflexes
- C. Pupil size and reaction to light
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Respiratory assessment (D) is the priority in Guillain-Barré syndrome due to the risk of respiratory muscle paralysis. Reflexes (B) are relevant but less urgent, and blood pressure (A) and pupils (C) are not primary concerns.
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
- A. Suction the client frequently while restrained
- B. Secure all 4 restraints to 1 side of bed
- C. Obtain a sitter for the client while restrained
- D. Request an order for a cough suppressant
Correct Answer: C
Rationale: Obtain a sitter for the client while restrained. The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.