- A nurse is teaching a client with an ileostomy about Bran foods that could result in the production of liquid stools. Which of the following foods that just arrived on the client’s meal tray should the nurse discourage the client from eating?
- A client with atrial fibrillation has been placed on war- Lettuce farin sodium (Coumadin). As part of the instructions Broccoli for the medication, which of the following foods does Cabbage the nurse tell the client to avoid? Select all that apply.
- The nurse is instructing a client with hypertension Spaghetti with about foods that are low in sodium. Which menu se- fresh tomatoes lections by the client indicate to the nurse that the Grilled chicken client understands what has been taught? Select all with turnip greens that apply.
- A nurse has provided dietary instructions to a client Scallops with a new diagnosis of gout. Which menu sugges- Chicken liver
tions by the client indicate to the nurse that the client needs additional instruction? Select all that apply.
- A clear liquid diet has been prescribed for client who Apple juice has just undergone surgery. Which foods should the Chicken broth nurse offer to the client? Select all that apply. orange gelatin
- Triamterene (Dyrenium) has been prescribed for a Prunes client with a history of hypertension. Which fruits Avocados should the nurse tell the client to avoid while taking Nectarines this medication? Select all that apply.
- Diverticulitis has been diagnosed in a client who High in fiber has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain, during the asymptomatic period, a soft diet that is:
- A nurse is teaching a client with heart disease about Avocados a low-fat diet. Which foods should the nurse tell the Green Olives
client to avoid? Select all that apply. Cream Cheese
- A regular diet has been prescribed for a client with a Chicken breast, leg fracture who has been placed in skeletal traction. broccoli, strawber-
Which foods that will promote wound healing does ries, milk the nurse encourage the client to select from the hospital menu?
- A client who experienced a brain attack (stroke) is ex- Peas periencing residual dysphagia. Which of the following foods would the nurse remove from the client’s meal tray?
- A client recovering from acute renal failure is being Potassium discharged home. The nurse knows that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in:
- A client is resuming eating after undergoing partial Drinking liquids gastrectomy. What does the nurse tell the client to with meals avoid doing as a means of minimizing the risk of complications?
- A client with renal calculi is instructed to follow an Spinach salad, alkaline ash diet. Which menu choice by the client milk, and a baindicates to the nurse that the client understands the nana prescribed regimen?
- A client who has sustained multiple fractures of the Right Heel left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client’s bed mobility. To which of the following high-risk areas must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?
- Which food should the nurse offer to a client who has Cooked custard been prescribed a full liquid diet?
- A client with heart failure and hypertension who has Turkey, baked been admitted to the hospital is unable to make her potato, salad with own selections from the menu. Which of the following oil and vinegar
meals does the nurse select for the client’s supper on the day of admission?
- The nurse teaches a client who has begun taking Peas phenelzine (Nardil), a monoamine oxidase inhibitor Broccoli (MAOI), about the medication. Which foods are al- Potatoes lowed in the diet of the client taking phenelzine? Select all that apply.
- A client with a genitourinary tract infection has been Alcohol prescribed metronidazole (Flagyl) and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states that she must avoid:
- Calcitriol (Rocaltrol) is prescribed for a client with Bran hypocalcemia. Which foods does the nurse, knowing Spinach
that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply.
- The nurse provides instructions to a client who is Coffee, cola, and beginning therapy with theophylline (Theo-24). The chocolate nurse recognizes that the client understands the instructions when the client states that he will be sure to limit consumption of:
- A client with a urinary tract infection has been started Rhubarb on nitrofurantoin (Macrodantin), a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to avoid while taking this medication?
- For which vitamin deficiency should the nurse moni- Vitamin B12 tor the client who is on a vegan diet?
- A client with cirrhosis has an increased ammonia One high in prolevel. Which diet does the nurse anticipate will be of tein benefit to the client?
- A nurse provides dietary instructions to a client with Roast turkey with cholecystitis. Which menu selection by the client in- a baked potato dicates to the nurse that the client understands the instructions?
- A client is found to have ulcerative colitis, and the Boiled potatoes nurse provides instructions to the client about the diet that he should follow while the disease is in remission. Which menu selection by the client indicates to the nurse that the client understands the instructions?
- A nurse has taught a client with a new colostomy Yogurt about measures to control stool odor in the ostomy Parsley drainage bag. Which of the following foods listed on Cranberry juice
the client’s shopping list indicate to the nurse that the client has understood the information? Select all that apply.
- A client with liver cancer who is undergoing Beef chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which of the following foods does the nurse suggest that the client avoid, knowing that it is most likely to taste bitter to the client?
- A client with diabetes mellitus who has been taught Omit 8 oz of about dietary management of the disease wishes to skim milk from that have 8 oz of nonfat yogurt with breakfast. The nurse meal determines that the client understands diet management when the client states that after eating the nonfat yogurt she will:
- A nurse is caring for a client with cirrhosis. As part of Peanuts the teaching regarding dietary means of minimizing Asparagus the effects of the disorder, the nurse educates the Whole-grain cereclient about foods that are high in thiamine. The nurse als determines that the client has the best understanding of the material if the client states to increase the intake of which of the following? Select all that apply.
- A nurse is monitoring the nutritional status of a client Daily weight receiving enteral nutrition. Which of the following parameters does the nurse use to determine the effectiveness of the tube feedings?
- A nurse is instructing a client in the first trimester My risk for malof pregnancy about nutrition. Which statement by the nourishment is client indicates the need for further instruction? much higher while I’m pregnant
- A client who has recently been started on enteral Lactose feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which of the following ingredients is the nurse looking for?
- A nurse provides dietary instructions to a client with Lentils iron-deficiency anemia. Which of the following foods Raisins does the nurse recommend to the client? Select all Kidney beans that apply.
- A client has a serum sodium level of 151 mEq/L, American cheese and the nurse provides instruction regarding foods to avoid. Which of the following menu choices by the client indicates to the nurse that the client needs further instruction?
- A nurse instructs a client at risk for hypokalemia Eggs about the foods high in potassium that should be included in the daily diet. Which of the following menu selections, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction?
- A nurse is providing dietary instructions to a client Meats and citrus with tuberculosis. Which of the following foods would fruit the nurse specifically instruct the client to include more of in the daily diet?
- A nurse is providing dietary instructions to a client To increase the inwith uric acid renal calculi. The nurse tells the client: take of legumes
- The nurse instructs a nursing assistant that a client Asking the client who is recovering from a myocardial infarction re- to wash his arms quires a complete bed bath. The nurse would intervene if the nurse observed the nursing assistant:
- A nurse asks a nursing assistant to provide afternoon Assist the client in care to a client. The nurse expects that the nursing washing his hands
assistant will: and face and
performing mouth care, offering a bedpan or urinal, and straightening the bed linens
- A client requires a partial bed bath. The nurse, giving Bathe the client’s instructions to a nursing assistant about the bath, body parts that,
tells the nursing assistant to: if left unbathed,
would give rise to discomfort or odor
- A nursing assistant is providing morning care to a Giving the client a client with a fractured leg who is in skeletal trac- complete bed bath tion. The nurse determines that the nursing assistant needs instruction regarding the guidelines for client bathing if she sees the nursing assistant:
- A nurse notes documentation in a client’s medical Has a diminished record indicating that the client is experiencing olig- capacity to form uria. On the basis of this notation, the nurse deter- urine mines that the client:
- A nurse is providing information to a mother of a That a child can1-year-old who has asked about bladder-training her not control urina-
child. The nurse tells the mother: tion until the age of
18 to 24 months
44.
A client has been found to have a bladder infection. Ureterovesical Which of the following areas of dysfunction would junction cause the nurse to monitor the client most closely for signs of a kidney infection?
- A nurse is caring for a client whose urine output was Release of 25 mL for 2 consecutive hours. Which of the following dopamine client-related factors does the nurse recognize as increasing blood flow to the kidneys?
- A nurse is caring for an older adult client. Which of Urine-concentratthe following occurrences does the nurse recognize ing ability as part of the normal aging process? increases.
- An adult client rings the call bell and asks the nurse 400 mL for assistance in getting to the bathroom to void. How much urine does the nurse estimate that the client has in her bladder if she is feeling a sensation of fullness?
- A client taking a potassium-sparing diuretic has a Increased sodium serum potassium level of 5.8 mg/dL. The nurse under- excretion stands that the kidneys will respond with:
- A nurse has administered a dose of furosemide Loop of Henle (Lasix) to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on the:
- A client tells the nurse that he is feeling fatigued Nocturia because he must get up several times during the night to urinate. The nurse documents that the client is experiencing:
- A client tells the nurse that during the past 2 weeks Drinking an exher urine output has been greater than usual. The cessive amount of
nurse, gathering subjective data from the client, most coffee appropriately asks the client whether she has been:
52.
A nurse is caring for a client who has a fever and is Urine output will diaphoretic. The nurse monitors the client’s urinary be decreased output and laboratory values, anticipating that the client’s:
- A nurse is instructing a client about the foods that will Plums acidify the urine and inhibit the growth of microorgan- Prunes isms. Which foods does the nurse tell the client are Cranberries most likely to acidify the urine? Select all that apply.
- A nurse is caring for a client who has just returned Turning on the wafrom a cardiac catheterization through the right side ter in the sink in of the groin. The client tells the nurse that he feels the the client’s room urge to urinate. The nurse assists the client in using and allowing it to a urinal, but the client is unable to void. Which of the run following actions should the nurse take to stimulate the client’s micturition reflex?
- A nurse provides information to a client about the im- 2000 to 2500 mL portance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day?
- A nurse provides instructions to a female client re- That she should garding the procedure for collecting a midstream cleanse the perurine sample. What should the nurse tell the client? ineum from front to back
- A nurse is monitoring a client’s fluid balance. Which Intake 1500 mL, of the following 24-hour intake and output totals indi- output 1400 mL cates to the nurse that the client has the proper fluid balance?
- A physician states that a client’s insensible fluid loss Skin and mechanis approximately 600 mL/day. The nurse interprets ical ventilator this statement to reflect fluid loss occurring through the:
- A nurse has taught a client how to ambulate with the The client moves use of a cane. The nurse determines that the client the cane and the needs additional instruction on observing that: unaffected side together
- A nurse provides instructions to a client about pre- Injury to the venting injury while using crutches. The nurse tells nerves the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in:
- A nurse has taught a client how to stand on crutches. 8 inches to the The nurse determines that the client understands the front and side of instructions if the client places the crutches: the toes
- A nurse is providing instructions to a client regarding It is not safe the use of crutches. Which of the following informa- to use someone tion should the nurse include in the teaching plan? else’s crutches.
Select all that apply. The client should
use both crutches when navigating stairs.
- A client with right-sided weakness must learn how to Left hand, 6 inchuse a cane. The nurse tells the client to position the es lateral to the left
cane by holding it with the: foot
- A nurse is evaluating the client’s use of a cane for Moves the cane left-sided weakness. The nurse determines that the when the right leg client is using the cane incorrectly if the client: is moved
- A nurse is repositioning a client who has returned to Pillow to keep the the nursing unit after internal fixation of a fractured right leg abducted
right hip. The nurse should use a: while turning the
client
- A nurse has a prescription to get the client out of Applying a knee bed and into a chair on the first postoperative day immobilizer before after total knee replacement. Which of the following getting the client actions should the nurse take to protect the knee? up, then elevating
the affected leg
while the client is sitting
- The nurse is supervising a nursing assistant in caring Having the client for a client who has just undergone lumbar spinal assist by using the fusion after herniation of a lumbar disc. Which of overhead trapeze the following actions by the nursing assistant while repositioning the client would cause the nurse to intervene?
- A nurse has taught the client with a herniated lumbar “I should get out disk about proper body mechanics and other infor- of bed by sitting mation about low back care. The nurse determines up straight and that the client needs further instruction if the client swinging my legs
says: over the side of the
bed.”
- A client has been placed in Buck’s extension traction. Slightly elevating The nurse can provide counter traction to reduce the foot of the bed shear and friction by:
- A nurse is inserting an indwelling urinary catheter Aspirating the fluinto the urethra of a male client. As the nurse inflates id, advancing the the balloon, the client complains of discomfort. The catheter farther,
appropriate nursing action is: and reinflating the
balloon
- A nurse is inserting an indwelling urinary catheter Inserts the into a female client. As the catheter is inserted into catheter 2.5 to 5
the urethra, urine begins to flow into the tubing. At cm and inflates
this point, the nurse: the balloon
- A nurse is preparing to administer an enema to a Left lateral sims client. In which of the following positions does the nurse place the client?
- A nurse is providing information to the mother of an The neuromuscu-
18-month-old about bowel training. The nurse should lar development
tell the mother that: needed to control
defecation does
not take develop
until 2 to 3 years of
age
- A nurse is developing a plan of care for an older client Providing cooked who is being admitted to a long-term care facility. fruits such as Which intervention should the nurse include in the prunes or apricots plan of care to help maintain an appropriate bowel elimination pattern?
- A nurse is developing a bowel-training program for a Providing privacy client after a stroke. Select the interventions that are and time for defeappropriate for inclusion in the plan. Select all that cation
apply. Assisting the
client into a sitting position
Initiating defecation measures every day at the same time
Administering a cathartic suppository a half-hour before defecation time
- A physician has prescribed a cleansing enema for an 1000 mL adult client. The nurse understands that the maximal volume of fluid that can be administered is:
- A nurse administers a tap water enema (1000 mL) to Document the rean adult client who is constipated. The client defe- sults cates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should:
- A nurse administers an oil retention enema to a client. Retain the enema Afterward, the nurse instructs the client to: for several hours
- 18 inches
A nurse is administering a high cleansing enema. At what level above the client’s hips should the nurse place the enema bag?
- A physician prescribes “enemas until clear” for a Notify the physiclient. The nurse has administered three enemas to cian the client, but the client is still passing brown stool and fluid. The nurse should:
- A nurse is preparing to administer a soap suds enema 4 inches to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client’s rectum a maximal distance of:
- A nurse is administering an enema to a client. While Clamp the enema the enema solution is being instilled, the client com- bag tubing plains of abdominal cramping. The nurse should:
- nurse is preparing to perform a digital removal of Continue the digifeces on a client with an impaction. The nurse checks tal removal procethe client’s heart rate before performing the proce- dure dure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client’s heart rate again and counts 82 beats per minute. The nurse should:
- A nurse is developing a plan of care for a client who Asking the client reports difficulty sleeping. Which initial intervention what she does to does the nurse include in the plan of care? prepare for sleep
- A home care nurse makes a visit to a new mother who “Most newborns delivered a 7-lb girl 72 hours ago. The mother tells the sleep about 16 nurse that her newborn seems to sleep almost all day. hours a day” The nurse most appropriately responds by telling the mother that:
86.
An older adult client tells the nurse that she is tired This is a normal during the day because she awakens frequently dur- occurrence as a ing the night. The nurse should tell the client that: person gets older
- A nurse is preparing a list of measures that will help Adjust the room promote sleep. Identify the measures that would be temperature to a included on the list. Select all that apply. comfortable level.
Eliminate lights, noise, and other environmental distractions.
Get up at the same time each day and avoid
naps during the day
- A client asks a nurse about complementary and al- Muscle relaxation ternative measures to promote sleep. What does the techniques nurse suggest?
- A nurse notes that a client has a diagnosis of acute A result of injury back pain. The nurse understands that one of the characteristics of acute pain is:
- The nurse is assigned to care for four clients. Which A client with osclient does the nurse believe is likely to experience teoarthritis chronic pain?
- A nurse develops a plan of care for a postoperative Encouraging client who is receiving intravenous morphine sulfate coughing and every 4 hours as needed for pain. Which priority in- deep breathing tervention does the nurse include in the plan?
- A client is receiving intravenous meperidine hy- Tachycardia drochloride (Demerol) as needed for postoperative Hypotension pain. For which side effects does the nurse assess Mental clouding the client while he is receiving this medication? Select all that apply.
- Codeine sulfate is prescribed for a client with severe Volume of urine back pain. Which of the following parameters does output the nurse monitor while the client is taking this med- Frequency of bow-
ication? Select all that apply. el movements
- A client requests the use of an alternative or comple- Becomes less mentary therapy to help control pain and asks about aware of pain by the use of guided imagery. The nurse responds by creating and then telling the client that in this technique, the client: concentrating on a mental image
- A client has been told to apply cold packs to a knee Reduces blood injury, and the client asks the nurse how this will help flow to the extremthe injury. The nurse explains that a cold pack: ity
- A client arrives at the emergency department after Consult with the sustaining an ankle injury, and the physician pre- physician before scribes the application of a cold compress to the applying the cold ankle. The nurse, preparing to apply the compress, compress
assesses the ankle and notes that it is extremely edematous. The nurse should:
- A nurse provides instructions to a client about the “I can pin the pad use of an electric heating pad. The nurse determines around the affectthat the client needs further instruction if the client ed area.” states:
- Which client does the nurse recognize as being at the An older client greatest risk for injury resulting from the use of heat or cold application?
- A client about to undergo surgery is instructed in The client adminpostoperative pain relief measures is asked whether isters his own he would like to use a patient-controlled analgesia medication by (PCA) pump. The client asks the nurse to describe the pressing a control pump. The nurse should tell the client that: button
- Which clients does the nurse recognize as candi- A client who has dates for patient-controlled analgesia (PCA)? Select undergone colec-
all that apply. tomy
A client with acute pancreatitis A client who has undergone gastrectomy
