Nokea
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
- A. Eat large amounts of rice.
- B. Increase the amount of fruits and vegetables in your diet.
- C. Ask the doctor for a prescription for a drug such as diphenoxylate hydrochloride and atropine sulfate (Lomotil).
- D. Drink fluids only with meals.
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.
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The preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
- A. Explain that visitors are limited to two per client
- B. Ask the client's roommate if he/she objects to so many persons in the room
- C. Ignore the large number of people and the chanting
- D. Arrange for the group to go to the conference room or the chapel
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
It is MOST important for the nurse to take which of the following actions?
- A. Administer the medication slowly, at 25-25 cc/h.
- B. Change the primary IV solution.
- C. Hang the piggyback infusion bag higher than the primary infusion bag.
- D. Obtain an infusion pump prior to administration.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
A teenaged client states that she drinks 'lots' of fluids and still feels thirsty.
It is MOST important for the nurse to ask which of the following questions?
- A. Has your weight recently changed?'
- B. What medications do you take?'
- C. Do you have any allergies to food or medication?'
- D. How often do you menstruate?'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the symptoms. (1) correct-excessive thirst and weight loss are two notable symptoms of diabetes mellitus (IDDM) (2) does not provide useful information related to the assessment information (3) does not provide useful information related to the assessment information (4) does not provide useful information related to the assessment information
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Lithium level of 2.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Creatinine 1.0 mg/dL.
Correct Answer: A
Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range 0.6–1.2 mEq/L), risking seizures or coma, requiring immediate intervention. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL do not indicate complications.
A baby girl weighing 7 lb 4 oz with Apgar scores of 7 and 8 at one and five minutes is admitted to the nursery. Her mother is a type I diabetic.
The nurse knows the infant is at GREATest risk for developing
- A. hypovolemia.
- B. hypoglycemia.
- C. hyperglycemia.
- D. cold stress.
Correct Answer: B
Rationale: Strategy: Determine the cause of each answer choice. (1) no change in blood volume for infant of diabetic mother (2) correct-fetus produces increased insulin to match mother's increased glucose level during pregnancy, infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment, increases metabolic rate, infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes, not expected with diabetic mother