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The nurse is developing a care plan with a client who had a laryngectomy 3 days ago. The nurse should instruct the client to do which of the following to assure adequate nutrition. Select all that apply.
- A. Weigh weekly and report weight loss.
- B. When eating, sit and lean slightly forward.
- C. Have serum albumin level checked regularly.
- D. Administer enteral tube feedings as ordered.
- E. Manipulate the nasogastric tube daily.
Correct Answer: A,B,C,D
Rationale: To ensure adequate nutrition post-laryngectomy, the client should monitor weight, sit and lean forward to aid swallowing, check serum albumin for nutritional status, and use enteral feedings as ordered. Manipulating the tube is not recommended to avoid dislodgement.
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A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply.
- A. A 32-year-old female who delivered a 9½-lb infant.
- B. A 44-year-old Native American Indian who has a body mass index (BMI) of 32.
- C. An 18-year-old Hispanic who jogs four times a week.
- D. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes.
- E. A 12-year-old who is overweight.
Correct Answer: A,B,D,E
Rationale: Risk factors for type 2 diabetes include history of delivering a large infant, obesity (BMI >30), family history, hypertension, and being overweight, especially in youth. Regular exercise reduces risk, making the 18-year-old less likely to be at risk.
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. Which of the following is the most effective nursing intervention to relieve this discomfort?
- A. Encourage the client to ambulate.
- B. Insert a rectal tube.
- C. Insert a nasogastric (NG) tube.
- D. Encourage the client to drink carbonated liquids.
Correct Answer: A
Rationale: Ambulation stimulates bowel motility, relieving gas pains effectively and safely.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation?
- A. Carefully test the temperature of bath water.
- B. Avoid kitchen activities because of the risk of injury.
- C. Avoid hot water bottles and heating pads.
- D. Inspect the skin daily for injury or pressure points.
- E. Wear warm clothing when outside in cold temperatures.
Correct Answer: A,C,D,E
Rationale: Testing bath water temperature (A), avoiding hot water bottles/heating pads (C), daily skin inspection (D), and wearing warm clothing (E) prevent injury due to impaired sensation. Avoiding kitchen activities entirely is overly restrictive.
An overweight client taking warfarin (Coumadin) has a nursing diagnosis of ineffective tissue perfusion related to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin
- B. Encourage a reduced-calorie, reduced-fat diet
- C. Inspect the involved areas daily for new ulcerations
- D. Instruct the client to limit activities of daily living (ADLs)
- E. Use an electric razor to shave
Correct Answer: B,C,E
Rationale: Rationales: B) A reduced-calorie, reduced-fat diet helps manage weight and reduce atherosclerosis progression, improving arterial blood flow. C) Daily inspection for ulcerations is essential in PVD to detect early skin breakdown due to poor perfusion. E) Using an electric razor minimizes the risk of cuts and bleeding, which is critical for a client on warfarin. A) Applying lanolin or petroleum jelly is not directly related to improving tissue perfusion. D) Limiting ADLs is incorrect, as moderate activity promotes circulation unless contraindicated.
A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client?
- A. Monitor the laboratory values.
- B. Observe neurologic function every 15 minutes.
- C. Observe the puncture site for swelling and bleeding.
- D. Monitor skin warmth and turgor.
Correct Answer: C
Rationale: Observing the puncture site for swelling and bleeding is critical post-catheterization to detect complications like hematoma or hemorrhage.