Nokea
The nurse is instructing a Hindu client to increase protein in the diet. Which of the following foods are appropriate to include in this client's diet? Select all that apply.
- A. Lentil soup.
- B. Hamburger.
- C. 3 mm.
- D. Veal cutlet.
- E. Broiled fish sandwich.
Correct Answer: A
Rationale: Hindus typically follow a vegetarian diet, so lentil soup is appropriate, while meat-based options like hamburger, veal, and fish are not.
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A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
- A. Allow the client to grieve for body image changes.
- B. Restrict foods that are high in potassium.
- C. Restrict fluid intake to 1,000 mL/day.
- D. Assess the client's mental status regularly.
Correct Answer: D
Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.
You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
- A. A prolapsed stoma
- B. A vitamin B12 deficiency
- C. Nocturnal enuresis
- D. GI stone formation
Correct Answer: A
Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.
A client with chronic kidney disease is on a fluid restriction. How should the nurse calculate the client's daily fluid intake?
- A. Based on urine output plus 500 mL
- B. 1,000 mL regardless of weight
- C. 20 mL/kg of body weight
- D. Unlimited unless edema is present
Correct Answer: A
Rationale: Fluid intake in chronic kidney disease is typically calculated as urine output plus 500 mL to replace insensible losses while preventing fluid overload.
The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the nurse is to:
- A. Prevent clots.
- B. Remove air.
- C. Remove fluid.
- D. Facilitate 'milking' of the tubes.
Correct Answer: B, C
Rationale: Chest tubes are placed to remove air (pneumothorax) and fluid (hemothorax or pleural effusion) from the pleural space to restore negative pressure and lung expansion. Preventing clots or milking tubes is not their primary purpose.
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
- A. 1 to 2 mL/kg/hour.
- B. 3 to 5 mL/kg/hour.
- C. 6 to 8 mL/kg/hour.
- D. 10 to 12 mL/kg/hour.
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.