Nokea
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
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The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse's best response?
- A. This is an expected finding after administration of barium.
- B. Describe any abdominal pain you had when passing the stool.
- C. What foods or fluids did you eat after you completed the test?
- D. You need to increase the amount of water you are drinking.
Correct Answer: A
Rationale: A: Pale stools are expected due to residual barium. B: Pain doesn't cause pale stools. C: Diet doesn't affect barium-related stool color. D: Water aids barium passage but isn't indicated for soft stools.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?
- A. Adult who underwent ileostomy surgery because of a perforated bowel
- B. Adult who has a productive cough and is receiving oxygen by nasal cannula
- C. Adult who develops thrombocytopenia after receiving chemotherapy treatments
- D. Adult who has hypothermia after being outside in a below-zero temperature
Correct Answer: C
Rationale: C: Thrombocytopenia increases bleeding risk, making rectal temperatures unsafe. A: Ileostomy doesn't affect rectal area. B: Cough and oxygen don't contraindicate rectal temperatures. D: Rectal temperatures are used for hypothermia.
Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow's milk
Correct Answer: C
Rationale: Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be a gluten-free food if they are specially labeled, but many are processed on the same equipment as wheat and so they should not automatically be considered a safe item. Unless marked, granola typically contains oats that could have been exposed to gluten. While fresh fruit is safe, dried and prepackaged fruits may contain additives that contain gluten. Rye is wheat derivative, and many cream sauces contain flour as a base.
The client with a new colostomy asks how to deal with gas coming from the stoma. To respond to the client's concern, the nurse should ask the client to take which action? Select all that apply.
- A. Describe the dietary intake, including types of foods.
- B. Include cruciferous vegetables in the diet daily.
- C. Decrease fluid intake to 1200 mL per 24 hours.
- D. Prick the colostomy stoma pouch with a pin.
- E. Limit intake of gas-producing carbonated sodas.
- F. In the bathroom, open the pouch clamp to release gas.
Correct Answer: A,E,F
Rationale: A: Assessing diet identifies gas-producing foods. E: Limiting carbonated drinks reduces gas. F: Releasing gas in a bathroom controls odor. B: Cruciferous vegetables increase gas. C: Reduced fluid risks dehydration. D: Pricking the pouch causes leaks and odor.