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The nurse is caring for the client one (1) day postoperative sigmoid colostomy. Which independent nursing intervention should the nurse implement?
- A. Change the infusion rate of the intravenous fluid.
- B. Encourage the client to ventilate feelings about body image.
- C. Administer opioid narcotic medications for pain management.
- D. Assist the client out of bed to sit in the chair twice daily.
Correct Answer: B
Rationale: Encouraging ventilation of feelings about body image is an independent nursing intervention addressing psychosocial needs post-colostomy. IV rate, opioids, and ambulation require orders or are less psychosocial.
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The 20-year-old female is being admitted to the hospital with exacerbation of Crohn’s disease. The client is alert and oriented and has been taking azathioprine for disease control. Into which room should the charge nurse place the client?
- A. Private room across from the nurse’s station
- B. Room with a female who has Crohn’s disease
- C. Private room that has a private attached bathroom
- D. Room with an elderly female who is on bedrest
Correct Answer: C
Rationale: A. The client is alert and oriented; there is no need to be near the nurse’s station. B. The client is at an increased risk for infection and should have a private room rather than rooming with another female with Crohn’s disease. C. The client should be in a private room with a private bathroom due to an increased risk for infection with azathioprine (Imuran). Azathioprine suppresses cell-mediated immune responses and may cause bone marrow suppression. It is also a biohazard medication. D. The client is at an increased risk for infection and should have a private room rather than rooming with another female.
The nurse is teaching the American Diabetes Association diet to a client diagnosed with diabetes mellitus type 2. Which should the nurse teach the client?
- A. Instruct the client to weigh all food before cooking it.
- B. Teach the client to eat only carbohydrates if the blood glucose is low.
- C. Demonstrate how to determine the amount of carbohydrates being eaten.
- D. Explain that proteins should be 75% of the recommended diet.
Correct Answer: C
Rationale: Determining carbohydrate amounts (e.g., carb counting) is key for glycemic control in type 2 diabetes per ADA guidelines. Weighing food, carb-only for hypoglycemia, and high protein are incorrect.
The client has had a liver biopsy. Which postprocedure intervention should the nurse implement?
- A. Instruct the client to void immediately.
- B. Keep the client NPO for eight (8) hours.
- C. Place the client on the right side.
- D. Monitor blood urea nitrogen (BUN) and creatinine level.
Correct Answer: C
Rationale: Placing the client on the right side applies pressure to the biopsy site, reducing bleeding risk. Voiding, NPO status, and BUN/creatinine are not specific to liver biopsy care.
The client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? Select all that apply.
- A. Monitor diarrhea, charting amount, character, and consistency.
- B. Assess the client's tissue turgor every day.
- C. Encourage the client to drink carbonated soft drinks.
- D. Weigh the client daily in the same clothes and at the same time.
- E. Assist the client with a warm sitz bath PRN.
Correct Answer: A,B,D,E
Rationale: Monitoring diarrhea, assessing turgor, daily weighing, and sitz baths address dehydration, skin integrity, and comfort. Carbonated drinks may worsen diarrhea.
The nurse writes a problem 'low self-esteem' for a 16-year-old client diagnosed with anorexia. Which client goal should be included in the plan of care?
- A. The client will spend one (1) hour a day with the parents.
- B. The client eats 50% of the meals provided.
- C. Dietary will provide high-protein milk shakes (tid).
- D. The client will verbalize one positive attribute.
Correct Answer: D
Rationale: Verbalizing a positive attribute directly addresses low self-esteem by fostering positive self-perception. Time with parents, eating, and milk shakes are unrelated or nutritional.