Nokea
The nurse is educating a client who is 10 weeks pregnant about prenatal nutrition. The client is of normal weight. Which statement by the client indicates an understanding of weight gain during pregnancy?
- A. I should gain 15 to 20 pounds.
- B. I should gain 25 to 35 pounds.
- C. I should gain 35 to 40 pounds.
- D. I should gain 40 to 45 pounds.
Correct Answer: B
Rationale: Normal-weight women should gain 25-35 pounds during pregnancy, as per guidelines.
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The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma?
- A. 1/8 inch
- B. 1/4 inch
- C. 1/2 inch
- D. 1 inch
Correct Answer: A
Rationale: The size of the opening for the appliance is generally cut 1/8 inch larger than the size of the client's stoma. This minimizes the amount of exposed skin but does not put pressure on the stoma. The larger sizes leave too much skin area exposed for irritation by gastrointestinal contents.
The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration?
- A. Massage the IV site daily.
- B. Immobilize the extremity.
- C. Stabilize the cannula with tape.
- D. Cleanse the site daily with alcohol.
Correct Answer: C
Rationale: Stabilizing the cannula with tape prevents movement, reducing the risk of phlebitis and infiltration. Massaging the site can cause tissue damage, immobilizing the extremity is unnecessary, and alcohol cleansing causes skin drying and discomfort.
A client diagnosed with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client to take which medication?
- A. Aspirin
- B. Naproxen
- C. Ibuprofen
- D. Acetaminophen
Correct Answer: D
Rationale: The client should be advised to take analgesics that do not contain aspirin, such as acetaminophen. Aspirin is irritating to the gastrointestinal tract of the client with a history of gastritis. Other medications that are irritating to the gastrointestinal tract are the nonsteroidal antiinflammatory drugs naproxen and ibuprofen.
A client tells the nurse that he gets dizzy and lightheaded with each use of the incentive spirometer. The nurse asks the client to demonstrate the use of the device. Which action should the nurse expect to be a contributing factor in this client's symptoms?
- A. Inhaling too slowly
- B. Exhaling too slowly
- C. Not resting adequately between breaths
- D. Not forming a tight seal around the mouthpiece
Correct Answer: C
Rationale: Hyperventilation, caused by not resting adequately between breaths, is the most common cause of respiratory alkalosis, leading to lightheadedness and dizziness during incentive spirometer use. Inhaling or exhaling too slowly or not forming a tight seal may reduce effectiveness but does not cause these symptoms.
The school nurse provides teaching about the hazards of smoking to a group of high school students. Which comment by a student indicates the need for additional teaching?
- A. Chewing tobacco is much safer than is smoking tobacco.
- B. Smoking during pregnancy increases the risk of stillbirth.
- C. My health is at risk when my family smokes in the house.
- D. Inhaling smoke from other people is a public health issue.
Correct Answer: A
Rationale: All forms of tobacco use, including chewing tobacco, are health hazards. Smoking during pregnancy, smoking in a household, and second-hand smoke all present health hazards of tobacco use. Chewing tobacco is not safer than smoking and can lead to oral cancer and other health issues.