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What intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct Answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report any decrease in urinary output to the healthcare provider. Decreased urinary output in these clients may indicate a blockage or another complication, which requires immediate attention. Monitoring the stoma for signs of infection (Choice D) is important but not the priority when compared to a decrease in urinary output. Pouching the stoma with a one-inch margin around it (Choice A) is incorrect as it does not address the issue of decreased urinary output. Referring the client to the United Ostomy Association (Choice B) is not necessary in this immediate situation where a potential complication is suspected.
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The two members of the health care team who work closely to monitor drug-nutrient interactions are:
- A. Physician and nurse
- B. Physician and pharmacist
- C. Nurse and clinical dietitian
- D. Clinical dietitian and pharmacist
Correct Answer: D
Rationale: Clinical dietitians and pharmacists work together to manage drug-nutrient interactions. They have the expertise to understand how medications and nutrients can interact in the body, potentially affecting the effectiveness of treatment. Physicians and nurses may be involved in patient care, but when it comes to monitoring drug-nutrient interactions, the specialized knowledge of clinical dietitians and pharmacists is crucial. Nurses and physicians typically focus more on administering medications and managing overall patient care, rather than the specific interactions between drugs and nutrients.
The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus?
- A. Roast beef, brown rice, green beans, carrot and raisin salad, and milk
- B. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade
- C. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee
- D. Corn flakes with milk, whole wheat toast, and orange juice
Correct Answer: A
Rationale: The correct answer is A. Roast beef is high in heme iron, which is best absorbed and helps treat iron deficiency anemia. Choices B, C, and D do not contain significant amounts of heme iron or other iron-rich foods that would be beneficial in managing iron deficiency anemia. Cheese pizza, scrambled eggs, bacon, white toast, corn flakes, and whole wheat toast do not provide the necessary heme iron needed to address the client's condition.
Which intervention should the nurse implement for the client who has an ileal conduit?
- A. Pouch the stoma with a one-inch margin around the stoma
- B. Refer the client to the United Ostomy Association for discharge teaching
- C. Report to the healthcare provider any decrease in urinary output
- D. Monitor the stoma for signs and symptoms of infection every shift
Correct Answer: C
Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.
Which of the following nursing interventions is important for a client scheduled to have a Guaiac Test?
- A. Avoid turnips, radish, and horseradish 3 days before
- B. Continue iron preparation to prevent further loss
- C. Do not consume meat 12 hours before the procedure
- D. Encourage consumption of caffeine and dark-colored foods
Correct Answer: A
Rationale: The correct answer is A. Turnips, radish, and horseradish are known to cause false-positive results in a Guaiac Test, which is used to detect blood in the stool. Avoiding these foods is crucial to ensure accurate test results. Choice B is incorrect as iron preparation is not directly related to the Guaiac Test. Choice C is incorrect because avoiding meat is not specifically necessary before a Guaiac Test. Choice D is incorrect as caffeine and dark-colored foods can potentially interfere with test results, so they should not be encouraged.
A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?
- A. Obtain a court order for the surgery
- B. Sign the informed consent on behalf of the client
- C. Send the client to surgery without the consent form being signed
- D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers
Correct Answer: D
Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.