Nokea
To ensure client safety, which assessment is most important for the nurse to make before advancing a client from liquid to solid food?
- A. Bowel sounds
- B. Chewing ability
- C. Current appetite
- D. Food preferences
Correct Answer: B
Rationale: The nurse needs to assess the client's chewing ability before advancing a client from liquid to solid food. It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing because of the risk of aspiration. Bowel sounds should be present before introducing any diet, including liquids. Appetite will affect the amount of food eaten, but not the type of diet prescribed. Food preferences should be ascertained on admission assessment.
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The nurse provides information to a client with a colostomy. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
- A. Parsley
- B. Yogurt
- C. Buttermilk
- D. Cucumbers
- E. Cauliflower
- F. Cranberry juice
Correct Answer: A,B,C,F
Rationale: The nurse should provide information about foods and measures that will prevent odor from a colostomy. Parsley, yogurt, buttermilk, and cranberry juice will prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will also eliminate odors. Foods that cause flatus and thus odor, including broccoli, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas, should be avoided.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? Select all that apply.
- A. Lift the cast using the fingertips.
- B. Place the child on a firm mattress.
- C. Direct a fan toward the cast to facilitate drying.
- D. Support the cast and adjacent joints with pillows.
- E. Place the extremity with the cast in a dependent position.
- F. Reposition the extremity with the cast every 2 to 4 hours.
Correct Answer: B,C,D,F
Rationale: To help the cast dry, the child should be placed on a firm mattress. A fan may be directed toward the cast to facilitate drying. Once the cast is dry, the cast should sound hollow and be cool to touch. The cast and adjacent joints should be elevated and supported with pillows. To ensure thorough drying, the extremity with the cast should be repositioned every 2 to 4 hours. The cast is lifted by using the palms of the hands (not the fingertips) to prevent indentation in the wet cast surface. Indentations could possibly cause pressure on the skin under the cast.
A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.
- A. Cardiac murmur
- B. Cardiac enlargement
- C. Cool pale skin over the joints
- D. White painful skin lesions on the trunk
- E. Small nontender lumps on bony prominences
- F. Purposeless jerky movements of the extremities and face
Correct Answer: A,B,E,F
Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neurovascular status? Select all that apply.
- A. Pain level
- B. Urinary output
- C. Ability to move all extremities
- D. Capillary refill in all extremities
- E. Ability to flex and extend the feet
- F. Ability to detect sensations in all extremities
Correct Answer: C,D,E,F
Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks, including circulation, sensation, and motion, should be done at least every 2 hours. Level of pain and urinary output are important postoperative assessments, but neurovascular status is more important.