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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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A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention should the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube to help assure the effectiveness of the procedure?
- A. Ambulate the client.
- B. Clamp the chest tube.
- C. Ask the client to cough and deep breathe.
- D. Ask the client to remain in a side-lying position.
Correct Answer: B
Rationale: After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on primary health care provider preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.
The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation should provide which information? Select all that apply.
- A. Eat bland foods.
- B. Avoid alcohol ingestion.
- C. Avoid cigarette smoking.
- D. Avoid caffeinated beverages.
- E. Eat small meals and snacks high in calories.
- F. Eat high-fat, low-protein, high-carbohydrate meals.
Correct Answer: A,B,C,D,E
Rationale: Chronic pancreatitis is a progressive, destructive disease of the pancreas, characterized by remissions and exacerbations (recurrence). Measures to prevent an exacerbation include eating bland, low-fat, high-protein, moderate-carbohydrate meals; avoiding alcohol ingestion, nicotine, and caffeinated beverages; eating small meals and snacks high in calories; and avoiding gastric stimulants such as spices.
A client who undergoes a gastric resection is at risk for developing dumping syndrome. Which manifestation should the nurse monitor the client for? Select all that apply.
- A. Pallor
- B. Dizziness
- C. Diaphoresis
- D. Bradycardia
- E. Constipation
- F. Extreme thirst
Correct Answer: A,B,C
Rationale: Dumping syndrome is the rapid emptying of the gastric contents into the small intestine that occurs after gastric resection. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Manifestations also include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
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.
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
- A. Where and when the medication was ingested
- B. The name and amount of ingested medication
- C. If the client continues to have suicidal ideations
- D. If there is a history of previous suicidal attempts
Correct Answer: B
Rationale: In an emergency, lifesaving facts are obtained first. The name of and the amount of medication ingested is of utmost importance in treating this potentially life-threatening situation. The remaining data can be assessed once the client's physical condition is stabilized.