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When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume?
- A. Oatmeal, cream of wheat, pureed liquid.
- B. Pureed beans, liquid protein supplements, milkshake.
- C. Pureed carrots, creamed soup, ice cream.
- D. Carbonated drinks, gelatin, broth.
- E. Water, tea, ice chips.
Correct Answer: D,E
Rationale: Clear liquids are transparent and easily digested.
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A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
- A. Confer with the physical therapist for correct crutch size.
- B. Ask the client to sit down while the crutch length is adjusted.
- C. Assess the client for signs of diminished circulation in the hands.
- D. Proceed with teaching the client how to walk with the crutches.
Correct Answer: D
Rationale: Three-finger gap indicates proper fit.
A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?
- A. Provide at least 20 minutes of back massage and gentle efleurage.
- B. Instruct the client to use guided imagery and slow rhythmic breathing.
- C. Place a hot water circulation device, such as an aquathermia pad, on the operative site.
- D. Tune to a television show or easy listening music to provide distraction.
Correct Answer: A
Rationale: Massage complements pain management.
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?
- A. Fibromyalgia
- B. Peptic ulcer disease.
- C. Hypertension
- D. Hypothyroidism.
Correct Answer: C
Rationale: OSA increases blood pressure via hypoxia.
While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, formed, and light brown. Which action should the nurse implement?
- A. Obtain the specimen from the client's current bowel movement.
- B. Contact the healthcare provider before obtaining the specimen.
- C. Wait to obtain the specimen until observable blood is present.
- D. Withhold specimen collection until tarry black stool is observed.
Correct Answer: A
Rationale: Normal stool is suitable for occult blood testing.
An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.