Nokea
The nurse is caring for the client with diverticulitis. The nurse should plan to instruct the client to avoid which food during an episode of diverticulitis?
- A. White bread
- B. Ripe banana
- C. Cooked oatmeal
- D. Iceberg lettuce
Correct Answer: C
Rationale: A. White bread is a recommended food for fiber-restricted diets. It contains less than 1 g fiber per ounce. B. Ripe bananas, canned soft fruits, and most well-cooked vegetables without seeds or skins are recommended for fiber-restricted diets. C. Cooked oatmeal contains 4 g of fiber per serving. Foods high in fiber should be avoided during an episode of diverticulitis, and foods should be restricted to low fiber or clear liquids. Once diverticulitis is resolved, the client should return to a high-fiber diet. D. Iceberg lettuce contains less than 1 g of fiber.
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Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
The nurse is caring for the client diagnosed with hemorrhoids. Which statement indicates further teaching is needed?
- A. I should increase fruits, bran, and fluids in my diet.
- B. I will use warm compresses and take sitz baths daily.
- C. I must take a laxative every night and have a stool daily.
- D. I can use an analgesic ointment or suppository for pain.
Correct Answer: C
Rationale: Daily laxatives are not necessary and may cause dependency; hemorrhoid management focuses on diet and symptom relief. Increased fiber/fluids, sitz baths, and analgesics are correct.
The nurse writes the problem 'risk for impaired skin integrity' for a client with a sigmoid colostomy. Which expected outcome would be appropriate for this client?
- A. The client will have intact skin around the stoma.
- B. The client will be able to change the ostomy bag.
- C. The client will express anxiety about the body changes.
- D. The client will maintain fluid balance.
Correct Answer: A
Rationale: Intact skin around the stoma directly addresses the risk for impaired skin integrity due to colostomy leakage or irritation. Other outcomes are unrelated or secondary.
The nurse is caring for the client who is one (1) day post-upper gastrointestinal (UGI) series. Which assessment data warrant intervention?
- A. No bowel movement.
- B. Oxygen saturation 96%.
- C. Vital signs within normal baseline.
- D. Intact gag reflex.
Correct Answer: A
Rationale: No bowel movement one day post-UGI series may indicate barium impaction, requiring intervention. Normal oxygen saturation, vital signs, and gag reflex are expected.
The client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement first?
- A. Check for a fecal impaction.
- B. Encourage the client to drink fluids.
- C. Check the chart for sodium and potassium levels.
- D. Apply a protective barrier cream to the perianal area.
Correct Answer: D
Rationale: Dark, watery stool risks perianal skin breakdown, so applying a barrier cream is the first intervention. Impaction is unlikely, fluids are secondary, and labs follow assessment.