Nokea
The nurse is teaching a client with a new colostomy about dietary management. Which food should the client avoid to reduce odor?
- A. Broccoli
- B. Rice
- C. Chicken
- D. Yogurt
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, increases colostomy odor due to sulfur compounds. Rice (B), chicken (C), and yogurt (D) are odor-neutral and appropriate.
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The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Double the dose to achieve therapeutic range.
- D. Administer half the dose.
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
- A. Hypotension
- B. Photosensitivity
- C. Excessive appetite
- D. Dryness of the mouth
Correct Answer: B
Rationale: Protection from the sun is important in clients taking phenothiazines like chlorpromazine because they burn easily and severely.
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
- A. Demand that she relax
- B. Ask what is the problem
- C. Stand or sit next to her
- D. Give her something to do
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.