Nokea
The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
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The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.
The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?
- A. I can begin driving my car again after I have been taking this medication for 2 weeks
- B. I need to contact my health care provider if I develop a rash while taking this medication
- C. I should report any new or increased anxiety I experience while taking this medication
- D. I understand that drowsiness is an adverse effect of this medication that may improve over time.
Correct Answer: A
Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.
A client at 20 weeks gestation reports 'running to the bathroom all the time,' pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
- A. Are you having any pain in your lower back or flank area?
- B. Do you wipe from front to back after urinating?
- C. Have you found that you urinate more frequently since becoming pregnant?
- D. Have you had a urinary tract infection in the past?
Correct Answer: A
Rationale: Back or flank pain suggests pyelonephritis, a serious complication of UTI in pregnancy, requiring urgent evaluation. Hygiene, frequency, and history are relevant but less critical than assessing for systemic infection.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.