Nokea
Which of the following diets would be most appropriate for the client with ulcerative colitis?
- A. High-calorie, low-protein.
- B. High-protein, low-residue.
- C. Low-fat, high-fiber.
- D. Low-sodium, high-carbohydrate.
Correct Answer: B
Rationale: A high-protein, low-residue diet is appropriate for ulcerative colitis as it provides nutrients for healing while minimizing bowel irritation. High-fiber diets may worsen symptoms during flares, and the other options are less tailored to the condition's needs. CN: Physiological adaptation; CL: Apply
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The nurse is preparing to administer a medication to a client with a history of Clostridium difficile infection. Which precaution is most important?
- A. Wear a face mask during administration.
- B. Use a dedicated stethoscope for the client.
- C. Administer the medication in a private room.
- D. Clean the medication cart with alcohol wipes.
Correct Answer: B
Rationale: Using a dedicated stethoscope for a client with C. difficile prevents cross-contamination, as the infection spreads via contact with contaminated surfaces. A face mask is unnecessary, a private room is ideal but not always required, and alcohol wipes are ineffective against C. difficile spores. CN: Safety and infection control; CL: Synthesize
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
The nurse is teaching a client about isoniazid (INH). Which of the following statements should the nurse include?
- A. This medication may turn your secretions reddish/orange.
- B. Yellowing of your eyes is a normal side-effect.
- C. A B-complex vitamin should be taken to help with the neuropathy.
- D. This medication will need to be taken every day for at least one week.
Correct Answer: C
Rationale: Isoniazid (INH) can cause peripheral neuropathy, and a B-complex vitamin (especially vitamin B6) is often recommended to help prevent or manage this side effect. Choice A is incorrect because reddish/orange secretions are associated with rifampin, not INH. Choice B is incorrect because yellowing of the eyes (jaundice) is a sign of hepatotoxicity, a serious adverse effect, not a normal side effect. Choice D is incorrect because INH treatment for tuberculosis typically lasts 6-9 months, not just one week.
A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy?
- A. The client adducts the affected leg every 2 hours.
- B. The client rolls the affected leg away from the body's midline twice per day.
- C. The client performs isometric exercises to the affected extremity three times per day.
- D. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.
Correct Answer: C
Rationale: Isometric exercises maintain muscle strength without moving the immobilized leg.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.