Nokea
The nurse is reviewing written medication instructions with a client who is prescribed colestipol hydrochloride. Which statement by the client indicates that the teaching has been effective?
- A. Vitamin C will help control unintended side effects.
- B. Vitamin B12 will help control unintended side effects.
- C. B-complex vitamins will help control unintended side effects.
- D. Fat-soluble vitamins will help control unintended side effects.
Correct Answer: D
Rationale: Colestipol hydrochloride, which is a bile-sequestering agent, is used to lower blood cholesterol levels. However, the bile salts (which are rich in cholesterol) interfere with the absorption of the fat-soluble vitamins A, D, E, and K, as well as folic acid. With ongoing therapy, the client is at risk for the deficiency of these vitamins and is counseled to take them as supplements.
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A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. The nurse educates the client on ways to conserve energy. Which statement indicates that the teaching was effective?
- A. Bathe before eating breakfast.
- B. Sit for as many activities as possible.
- C. Stand in the shower instead of taking a bath.
- D. Group all tasks to be performed early in the morning.
Correct Answer: B
Rationale: The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, and ironing. The client should also sit in a shower chair instead of standing while showering. The client needs to prioritize activities such as eating breakfast before bathing, and the client should intersperse each major activity with a period of rest.
The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?
- A. Prune juice needs to be included in my diet.
- B. I need to avoid strenuous activity for 4 to 6 weeks.
- C. My intake of water needs to be at least 6 to 8 glasses daily.
- D. I can't lift or push objects that weigh more than 30 pounds.
Correct Answer: D
Rationale: The client needs to be advised to avoid strenuous activity for 4 to 6 weeks and avoid lifting items that weigh more than 20 pounds. Straining during defecation is avoided to prevent bleeding. Prune juice is a satisfactory bowel stimulant. The client needs to consume a daily intake of at least 6 to 8 glasses of nonalcoholic fluids to minimize clot formation.
The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching?
- A. I will need to sleep on my right side.
- B. It's important that I don't carry heavy objects with the right arm.
- C. I will perform range-of-motion exercises routinely on my right arm.
- D. It's important that I report any right arm redness or drainage at the site.
Correct Answer: A
Rationale: Routine instructions to the client with an AV fistula, graft, or shunt include avoiding sleeping with the body weight on the extremity with the access site, avoiding carrying heavy objects or compressing the extremity that has the access site, performing routine range-of-motion exercises of the affected extremity, and reporting signs and symptoms of infection.
Cholestyramine is prescribed, and the nurse provides instructions to the client about the medication. Which client statement indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I need to mix the medication with juice or applesauce.
- C. I should increase my fluid intake while taking this medication.
- D. I should call my primary health care provider immediately if it causes constipation.
Correct Answer: D
Rationale: Common side effects of cholestyramine include constipation, nausea, indigestion, and flatulence. Therefore, it is not necessary to contact the primary health care provider immediately if constipation occurs. Cholestyramine must be administered with food to be effective. This medication should not be taken dry, and it can be mixed in water, juice, carbonated beverages, applesauce, or soup. Increasing fluids will minimize the constipating effects of the medication.
The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
- A. I need to eat a high-protein diet.
- B. I need to avoid exposure to sunlight.
- C. I need to wash my skin with a mild soap and pat it dry.
- D. I need to apply pressure on the irritated area to prevent bleeding.
Correct Answer: D
Rationale: The client receiving external radiation therapy should avoid pressure on the irritated area and wear loose-fitting clothing. Specific health care provider instructions would be necessary to obtain if an alteration in skin integrity occurred as a result of the radiation therapy. The remaining options are accurate measures regarding radiation therapy.