Nokea
Which of the following health promotion activities would be appropriate for the nurse to suggest that the client with cirrhosis add to the daily routine at home?
- A. Supplement the diet with daily multivitamins.
- B. Limit daily alcohol intake.
- C. Take a sleeping pill at bedtime.
- D. Limit contact with other people whenever possible.
Correct Answer: A
Rationale: Multivitamins (A) address nutritional deficiencies common in cirrhosis. Alcohol (B) must be completely avoided, sleeping pills (C) risk encephalopathy, and social isolation (D) is unnecessary.
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Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
- A. Slow, irregular respirations.
- B. Rapid, shallow respirations.
- C. Asymmetric chest excursion.
- D. Nasal flaring.
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
- A. Administer acetaminophen (Tylenol)
- B. Change the D5W to normal saline
- C. Discontinue the I.V.
- D. Place a warm compress on the area
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.