The nurse is caring for a client with a history of diverticulitis. Which of the following dietary recommendations should the nurse provide to prevent flare-ups?
- A. Increase intake of nuts and seeds.
- B. Follow a low-fiber diet.
- C. Consume a high-fiber diet.
- D. Avoid all dairy products.
Correct Answer: C
Rationale: A high-fiber diet promotes regular bowel movements and reduces pressure in the colon, preventing diverticulitis flare-ups. Nuts and seeds (A) may irritate diverticula, a low-fiber diet (B) worsens symptoms, and dairy restriction (D) is unnecessary unless lactose intolerant.
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A client with seizure disorder is to receive Dilantin (Phenytoin) and Phenobarbital. The nurse knows that when she administers Phenobarbital and Dilantin (Phenytoin):
- A. A larger dose of Phenobarbital might be required.
- B. A smaller dose of Phenobarbital might be required.
- C. There will be no need to alter the amount of Phenobarbital.
- D. The two drugs cannot be given together.
Correct Answer: A
Rationale: Phenytoin induces liver enzymes, potentially reducing phenobarbital levels, so a larger dose of phenobarbital may be needed.
Which of the following clients is at greatest risk for postpartal hemorrhage?
- A. A gravida 1 para 1 with an uncomplicated delivery of a 7-pound infant
- B. A gravida 1 para 0 with a history of polycystic ovarian disease
- C. A gravida 2 para 2 with a history of low birth weight infants
- D. A gravida 4 para 3 with a Caesarean section
Correct Answer: D
Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for postpartal hemorrhage due to multiparity and surgical delivery, which can lead to uterine atony and increased bleeding risk.
A nurse is assigned to care for a comatose diabetic on IV insulin therapy. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)?
- A. Check the client's level of consciousness
- B. Obtain the regular blood glucose readings
- C. Determine if special skin care is needed
- D. Answer questions from the client's spouse about the plan of care
Correct Answer: B
Rationale: The UAP can safely obtain blood glucose readings, which are routine tasks.
B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?
- A. Unlicensed assistive personnel (UAP)
- B. Senior nursing student
- C. PN
- D. RN
Correct Answer: D
Rationale: The RN is responsible for teaching and assessment associated with discharge and these activities cannot be delegated to the others listed.
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